Student Information: (Name of Student As Shown on Birth Certificate Or Passport)

Student Information: (Name of Student As Shown on Birth Certificate Or Passport)

/ Mt.LebanonSchool District
School Name • School Address • PittsburghPennsylvania 152__
Enrollment Form 105-A
Revised 1/5/2016 / PLEASE PRINT

Student Information: (Name of student as shown on Birth Certificate or Passport)

Student Last Name / First Name / Nick Name / Middle Name / Grade Entering
Street Address / City, State / Zip / Phone Number
/ /
Date of Birth (MM/DD/YY) / Gender / Age / Birth Certificate #/Passport # / City & State of Birth

Ethnicity:

Is the student Hispanic or Latino? / Yes No

Race: (Please check all that apply)

Asian / Black or African American / American Indian or Alaska Native
White / Native Hawaiian / Other Pacific Islander

Parent/Guardian Information:

Father: / Mother:
Last Name / First Name / Mid Initial / Last Name / First Name / Maiden
Address: / Address:
City / State / Zip / City / State / Zip
Home Phone / Cell Phone / Home Phone / Cell Phone
Email / Email
Place of Employment / Work Phone / Place of Employment / Work Phone

If parents reside at different addresses: Check if non custodial parent would like copies of mailings.

Proof of Residency Provided:
Address identification (sale/rental agreement, utility bill) must be verified by school office.

Shared or Non-Custodial Parent Information: (Complete only if applicable)

Student lives with: / Father / Mother / Step Parent (Name) / Other
Non Custodial Parent / Foster / Placing Agency
(Name) / (Name) / (Name)
Legal Custody (Choose one): / Joint / Sole:
Mother
Father / (Attached is a copy of the Court Order indicating limitations for non-custodial parent) Yes No
School Previously Attended: / Grade:
Previous School Address / City / State / Zip

For Students Who Receive Special Services: Please bring any current special education records with you for enrollment.

IEP (My child has a current IEP)
GIEP (My child has a current GIEP)
504 Service Agreement (My child has a current 504 Service Agreement)
English as a Second Language (ESL)
Date entered US / / / / (MM/DD/YY)
Date entered US school / / / / (MM/DD/YY)
Last year entered US school (K-12 only) / / / / (MM/DD/YY) / Grade
Other (Please explain)

*Complete for Non-Resident Student:

Student resides in: Foster Home Group Home Host Family

Contact Name / Address / City / State / Zip
Contact Phone Number:
Name of Placing Agency: / Agency Phone Number:
ParentSchool District of Residence: / Phone Number:
Address: / City: / State: / County:

Kindergarten Families ONLY:

Please provide any further information regarding placement:

______

Parent/Guardian Signature / Date / Driver’s License Number
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For Office Use Only

Registration Date: / Copies provided to:
Start Date: / Guidance Counselor
District Entry Date: / Special Education Teacher
School Entry Date: / Gifted Support Coordinator
State Entry Date: / ESL Coordinator
Grade: / Other
Homeroom:
Counselor:
Verifying Signature:
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