Student Enrollment Form Step 1 of 9 11% Student's LEGAL Name(Required) First Middle Last Grade Level(Required)PreschoolKindergarten1st2nd3rd4th5th6th7th8th9th10th11th12thDate of Birth MM slash DD slash YYYY Place of Birth City State / Province / Region AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone Student's First Language(Required) English Other Primary language spoken in the home(Required) English Other Language other than English spoken in the home(Required) No Other Student is:(Required) Male Female Student has a current Individual Education Plan (IEP)(Required) Yes No New/Transfer Student(Required) Yes No Last Non-BBBSD School Attended Last Grade LevelPreschoolKindergarten1st2nd3rd4th5th6th7th8th9th10th11th12thAddress of Last Non-BBBSD School Street Address City State / Province / Region ZIP / Postal Code Student EthnicityPart 1 ) Is student Hispanic or Latino?(Required) Yes No Part 2) Regardless of response to Part 1, select one or more of the race categories below(Required) Alaska Native American Indian Black (non-hispanic) Asian Caucasian Hispanic Native Hawaiian/Pacific Islander Select all that apply Parent/Guardian InformationWhile attending school, Student lives with:(Required) Mother and Father Mother Father Legal Guardian Other Parent/Guardian #1 Name(Required) First Last Relationship to Student(Required) Parent/Guardian #2 Name First Last Relationship to Student Parent/Guardian Mailing Address(Required) Street Address City State / Province / Region ZIP / Postal Code Home Phone(Required)Work PhoneCell PhoneParent/Guardian Email(Required) Emergency ContactEmergency Contact Name(Required) First Last Must be different from Parent/GuardianRelationship to Student(Required) Home Phone(Required)Work PhoneCell PhonePlease list all siblings school-age or younger and what school they attend, if applicableName First Last DOB MM slash DD slash YYYY School Name First Last DOB MM slash DD slash YYYY School Name First Last DOB MM slash DD slash YYYY School Name First Last DOB MM slash DD slash YYYY School Name First Last DOB MM slash DD slash YYYY School Name First Last DOB MM slash DD slash YYYY School Student HealthPlease provide the following information regarding the student’s health that the school should know.This students has:Asthma(Required) Yes No Diabetes(Required) Yes No Allergies(Required) Yes No Other(Required) Yes No If Other, please explain Migrant EducationMigrant Education is a federally funded program based on students whose family engages in seasonal work such as fishing away from their home. This funding has allowed BBBSD to supplement many of our existing programs.Question to Help Determine Program Eligibility: Did you or any member of your family travel to look for or get work in commercial or subsistence fishing in the last 3 years?(Required) Yes No If yes, a Migrant Education recruiter will contact you via telephone Parent on Active Duty Military Service(Required) Yes No Name First Last Parent/Guardian Signature(Required)Date MM slash DD slash YYYY
