To be completed by: Parent/Guardian FORM A

ISD 535 REGISTRATION FOR PUBLIC AND NONPUBLIC SCHOOLS- not needed for current RPS enrolee
Office of Registration & Records
615 7th Street SW
Rochester, MN55902 / Today’s Date / ESL
MCC / LANG / LLA / Enrollment Date: / Student ID / Res Dist / Grid #
Student’s (Legal) Last Name (Legal) First Name Middle / Sex
M ___
F ___ / Date of Birth(month/day/yr) / Grade / Has this student or any siblings ever attended any RochesterSchool? Yes _____ No _____
Student Address Lot/Apt # City State Zip / Home Phone / Social Security # * Optional: (Read reverse side)
Student lives with: (Check the one that applies) Both Parents___ Mother___ Father___ Step-Parent*___ Foster Parent*___ Guardian*___ Other*___ Alone___
*If other than parents, name and relationship: ______Employer: ______Work Phone:______
Father’s Employer/Phone: Mother’s Employer/Phone:
Legal Father of Student: Father living? Yes___No___
Full name ______
Last First Middle
Address (if different) ______Phone______
City______State ______Zip______/ Legal Mother of Student: Mother living? Yes___No___
Full name ______
Last First Middle Maiden
Address (if different) ______Phone______
City______State ______Zip______
STUDENT SUPPORT SERVICES INFORMATION: * Complete additional questions on reverse side.
Does your child have an IEP? If yes, please check student’s primary disability
__Autism Spectrum Disorders __Deaf and Hard of Hearing
__Developmental Cognitive Disability (Mild) __Developmental Cognitive Disability (Severe)
__Emotional-Behavioral Disorder __Other Health Disorder
__Physical Impairment __Specific Learning Disability
__Visual Impairment __Traumatic Brain Disorder
__Speech Language Impairment
Does your child require special transportation?(Circle) Wheelchair Seizures Car-seat Other
Does your child receive special accommodations at a school for a disability (504 Plan)? ___yes ___no
(If yes, please provide a copy for our records). / HOME LANGUAGE *
1st language learned by student: ______
Language normally used by student at home______
Language normally used by parents at home______
Does parent/guardian require an interpreter? ___yes___no
NEW US RESIDENT INFORMATION *
Date student entered the US ______
From which country ______Date started school______
Refugee_____ Immigrant_____
Have you moved to this school district within the last 3 years for temporary or seasonal agricultural or fishing work (migrant)? Yes___ No___ / ETHNIC/RACE:
* (please circle)
1. Am Indian
2. Asian
3. Hispanic
4. Black
5. White / TRANSPORTATION
SERVICES
If eligible, will child
use transportation
services?
___ Yes
___ No
SCHOOL DISTRICT WHERE PARENTS RESIDE:
School District Number County
School District Name
School District Address
City State Zip / REQUEST FOR HEALTH AND EDUCATIONAL RECORDS
School most recently attended by student:
Last date attended: ______
School District Number County
School Name
School Address
City State Zip
Parent/Guardian Signature: