Home Phone Cell Phone Home Phone Cell Phone. Email Email. Place of Employment Work Phone Place of Employment Work Phone.
Mt. Lebanon School District 7 Horsman Drive ~ Pittsburgh ~ Pennsylvania ~ 15228 To Provide the Best Education Possible for Each and Every Student
PLEASE PRINT
Enrollment Form 105-A
Student Information: (Name of student as shown on Birth Certificate or Passport) Student Last Name
First Name
Street Address
Nick Name
Middle Name
City, State
/ / Date of Birth (MM/DD/YY)
Gender
Zip
Birth Certificate #/Passport #
Age
Grade Entering
Phone Number
City & State of Birth
Ethnicity: Is the student Hispanic or Latino?
Yes
No
Race: (Please check all that apply) Asian White
Black or African American Native Hawaiian / Other Pacific Islander
American Indian or Alaska Native
Parent/Guardian Information: Father: Last Name
Mother: First Name
Mid Initial
Last Name
Address:
First Name
Maiden
Address:
City
State
Zip
Home Phone
Cell Phone
City
State
Home Phone
Email
Zip
Cell Phone
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: Non Custodial Parent
Father
Mother
Step Parent (Name) Foster
(Name)
Legal Custody (Choose one):
Placing Agency (Name)
Joint
Sole: Mother Father
Other
(Name) (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) (MM/DD/YY) Date entered US / / (MM/DD/YY) Date entered US school / / (MM/DD/YY) Last year entered US school (K-12 only) / / Grade Other (Please explain)
*Complete for Non-Resident Student: Student resides in: Foster Home Contact Name
Group Home
Address
Host Family City
State
Zip
Contact Phone Number: Name of Placing Agency:
Agency Phone Number:
Parent School District of Residence: Address:
Phone Number:
City:
State:
County:
Kindergarten Families ONLY: Please provide any further information regarding placement: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________
For Office Use Only Registration Date: Start Date: District Entry Date: School Entry Date: State Entry Date: Grade: Homeroom: Counselor: Verifying Signature:
Copies provided to: Guidance Counselor Special Education Teacher Gifted Support Coordinator ESL Coordinator Other
