Student Enrollment
2016-2017
This Space for Office Use Only
Student’s Current Grade ________________ ID# ________________
Date of Enrollment ___/___/____
Withdrawal Date ___/___/____
Student Information
Student’s Name: ______________________________________________
Last
First
Middle
Mailing Address: ______________________________________________
Street Address
City
Zip Code
PLEASE NOTE: Any change of address requires proof of residency.
Physical Address: _____________________________________________
Street Address
City
Zip Code
Social Security Number: __________________ Grade Level: __________
Date of Birth: _____/_____/_____
Gender:
Male
Female
Month
Day
Year
Birth City/State: _____________________Birth Country: _________________
Previous District/Campus: ____________________________
Previous City/State: _________________________________
Please check all that apply to your child:
First time in a Texas School?
Yes
No
First time in a Brenham ISD School?
Yes
No
*Are there any legal restriction or custody orders (signed by a judge )
regarding this student?
Yes
No
Has student been assigned to a Disciplinary Alternative Placement
Program within the past 12 months?
Yes
No
Has student ever been retained?
Yes
No If so, what grade? ________
Is your child receiving Special Education Services?
Yes
No
Is your child receiving Section 504 Accommodations?
Yes
No
Is your child in an English as a Second Language (ESL) or
bilingual program?
Yes
No
Has your child been identified as Gifted/Talented in a Texas School?
Yes
No
If Yes, which school district? ____________________________________________
Is your child in Foster care?
Yes
No
Is your child receiving Dyslexia services?
Yes
No
Additional Student Information
Names of students at this address (include grade level and campus name:
*If applicable, please list restrictions and/or explain custody guidelines.
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Emergency Contacts Other than Parent/Guardian
The following people may be contacted and may pick up this student from school other than Parent/Guardian:
Emergency Contact and Relationship
Home #
Work #
Cell #
Emergency Contact and Relationship
Home #
Work #
Cell #
Emergency Contact and Relationship
Home #
Work #
Cell #
Emergency Contact and Relationship
Home #
Work #
Cell #
Parent/Guardian
Parent/Guardian 1: _________________________________________________________
Relationship: ____________________________________ Date of Birth: ____/____/_____
Address: _______________________________________ City: ______________________
Home #: ____________________Work #: ____________________ Cell#: _____________
Employer: _________________________ Email Address: __________________________
Parent/Guardian 2: _________________________________________________________
Relationship: ____________________________________ Date of Birth: ____/____/_____
Address: _______________________________________ City: ______________________
Home #: ___________________Work #: ____________________ Cell #: ______________
Employer: _________________________ Email Address: __________________________
Child lives with:
Parent/Guardian 1
Parent/Guardian 2
Both
Disclaimer and Signature
Notice to the person enrolling the student: A person who knowingly falsifies information on a form required for a student’s enrollment in the District shall be liable to the District for tuition or other costs, as
provided in Education Code 25.001 (h), if the student is not eligible for enrollment but is enrolled on the
basis of false information. In addition, presenting false information or false records is a criminal offense
under Penal Code 27.10.
I certify that _____________________(student’s name) resides with his/her parent or legal guardian
within the boundaries of the Brenham Independent School District. I understand that I may incur a
charge of $2500 per year if I falsify residence information.
X_____________________________________________________ Date_______________
Parent/Guardian Signature
March 2016/ Form 1
Student Residency Questionnaire
2016-2017
Student Information
Section A
Name of School: ______________________________ Current Grade: _______
Where is the student presently living? (Check all that apply.)
Name of Student: __________________________________________________
In a Shelter (emergency, youth, domestic violence shelter, etc.)
Doubled-Up (living with friend/relative)
Unsheltered (cars, campgrounds, etc.)
Hotels/Motels
Previous Address: ___________________________________________________
Last
First
Middle
Student ID#: _____________________________ Date of Birth: ____/____/____
Unaccompanied Youth:
Yes
No
(Not in the physical custody of parent or guardian)
Street Address
This questionnaire is intended to address the McKinney-Vento Act 42 U.S.C.
11435 (MV ACT). The answers to this residency information help determine
the services the student may be eligible to receive.
City
State
Zip Code
Last School Attended: ________________________________________________
Full School Name
City
State
Zip Code
School aged siblings of student:
Name(s): __________________________________________________________
1. Is your current address a temporary living arrangement?
(Mark “Yes” if you are NOT living in your own home, renting an apartment or
on a lease.)
Yes
No
2. Is this temporary living arrangement due to loss of housing? (Fire, eviction,
loss of income, domestic violence, etc.)
Yes
No
3. Were you displaced from your home due to a Natural Disaster? (Hurricane,
tornado, etc.)
Yes
No
Type of Natural Disaster:
Hurricane: ______________________________________(Please Name)
Other: ________________________________________(Please Describe)
If you answered NO to all questions, please sign below and stop here.
If you answered YES to any question, please sign below and complete Section A.
Grade Level(s): _____________________________________________________
School(s): _________________________________________________________
Name of Parent(s)/Legal Guardian(s): ___________________________________
Current Address: ___________________________________________________
Street Address
___________________________________________________
City
State
Zip Code
___________________________________________________
Phone Number
Email Address
Presenting a false record or falsifying records is an offense under Section 37.10,
Penal Code and enrollment of a child under false documents subjects the person
to liability for tuition or other costs. TEC Sec.25.001(h) Education.
This Space for Office Use Only
I certify the above named student qualifies for the Child Nutrition Program under
the provisions of the McKinney-Vento Act.
Date: ________________ School District Representative: _________________
X__________________________________________
Signature of Parent Legal Guardian/Unaccompanied Youth
_____________________
Date
Notified Food Services _____ Notified Registrar _____ Other Action Taken _____
February 2016 / Form 2
Home Language Survey
2016-2017
English / Inglés
Name of Student: ____________________________________ Grade: ____________________ Name of School: __________________________________________
1. What language is spoken in your home most of the time? ______________________________________________________________________________________
2. What language does your child speak most of the time? _______________________________________________________________________________________
3. Was your child born in a country other than the United States?
Yes
No
If yes, where? ____________________________________________________
4. Has your child lived outside of the United States?
Yes
No
If yes, where? ____________________________________________________
5. Has your child attended school in the United States?
Yes
No
If yes, where? ____________________________________________________
____________________________________________
Parent/Guardian Signature
_________________
Date
Spanish / Español
Nombre del Estudiante: ________________________________ Grado: ______ Fecha de hoy: _______ Nombre de la Escuela: _______________________________
1. ¿Qué idioma se habla con mayor frecuencia en su hogar? _____________________________________________________________________________________
2. ¿Qué idioma habla su niño principalmente? _________________________________________________________________________________________________
3. ¿Nació su hijo(a) en un país fuera de los Estados Unidos?
Sí
No
¿Si su respuesta es sí, ¿dónde? ______________________________________
4. ¿Ha vivdo su hijo(a) fuera de los Estado Unidos?
Sí
No
¿Si su respuesta es sí, ¿dónde? ______________________________________
5. ¿Ha asistido su hijo(a) a alguna escuela en los Estados Unidos?
Sí
No
¿Si su respuesta es sí, ¿dónde? ______________________________________
____________________________________________
Firma del padre/tutor
This Space for Office Use Only
Student’s Current Grade ________________ ID# ________________
Official Enrollment Date on Campus: ___/___/____
_________________
Fecha
December 2015 / Form 3
Texas Education Agency
Texas Public School Student/Staff Ethnicity and Race Data Questionnaire
The United States Department of Education (USDE) requires all state and local education
institutions to collect data on ethnicity and race for students and staff. This information is used
for state and federal accountability reporting as well as for reporting to the Office of Civil Rights
(OCR) and the Equal Employment Opportunity Commission (EEOC).
School district staff and parents or guardians of students enrolling in school are requested to
provide this information. If you decline to provide this information, please be aware that the
USDE requires school districts to use observer identification as a last resort for collecting the
data for federal reporting.
Please answer both parts of the following questions on the student’s or staff member’s ethnicity
and race. United States Federal Register (71 FR 44866)
Part 1. Ethnicity: Is the person Hispanic/Latino? (Choose only one)
Hispanic/Latino - A person of Cuban, Mexican, Puerto Rican, South or Central American, or
other Spanish culture or origin, regardless of race.
Not Hispanic/Latino
Part 2. Race: What is the person’s race? (Choose one or more)
American Indian or Alaska Native - A person having origins in any of the original peoples
of North and South America (including Central America), and who maintains a tribal affiliation
or community attachment.
Asian - A person having origins in any of the original peoples of the Far East, Southeast
Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan,
Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
Black or African American - A person having origins in any of the black racial groups of
Africa.
Native Hawaiian or Other Pacific Islander - A person having origins in any of the original
peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White - A person having origins in any of the original peoples of Europe, the Middle East, or
North Africa.
________________________________
Student/Staff Name (please print)
________________________________
(Parent/Guardian)/(Staff) Signature
________________________________
Student/Staff Identification Number
________________________________
Date
Texas Education Agency – March 2009
February 2016
FAMILY SURVEY
2015-2016
Name of Child ____________________________________ Grade Level
_______________ Date ________________
School District ____________________________________ School Campus __________________________________
Dear Parents,
In order to better serve your children, the school district would like to identify students who may qualify to receive
additional educational services. The information provided below will be kept confidential.
Please answer the following questions and return this survey to your child’s school.
1. Did you seek or obtain employment (for wages) in agricultural or fishing related activities within the last three years?
(e.g., ranch work, field work, poultry production, canneries, lumbering, dairy work, meat processing, etc.)
Yes______
No______
2. Have you and your children traveled within the last three years to find the type of work mentioned in question #1?
Yes______
No_______
If you answered “No” to both of the questions above, stop here!
If you answered “Yes” to both questions above, provide the following information:
Name of child______________________________________________ Age______________ Grade_____________
Father/Guardian ______________________________ Mother/Guardian ___________________________________
Home Address_________________________________________________________________________________
Street
City
State
ZIP
Home Telephone Number _______________________________ Other Phone _____________________________
For questions, please contact Jackie Eckert
(979) 277-3700 or FAX (979) 277-3701
Brenham Independent School District
P.O. Box 1147
Brenham, TX 77834
Revised 01/15/2015
BISD Form 5
Request for Food Allergy Information 2016­2017 Texas Education Code Chapter 25, Section 25.0022 ­ Food Allergy Information Requested Upon Enrollment On enrollment of a child in public schools, a school district shall request, by providing a form or otherwise, that a parent or other person with legal control of the child under a court order: 1) Disclose whether the child has a food allergy or a severe food allergy that, in the judgement of the parent or other person with legal control, should be disclosed to the district to enable the district to take any necessary precautions regarding the child’s safety; and 2) Specify the food to which the child is allergic and the nature of the allergic reaction. A “severe food allergy” is a dangerous or life­threatening reaction of the human body to a food­borne allergen introduced by inhalation, ingestion, or skin contact that requires immediate medical attention. Please provide the following information regarding your child: Student Name: Date of Birth: Campus: Grade: ⬜ My child has a food allergy or severe food allergy. In my judgement, this allergy should be disclosed to allow the district to take any necessary precautions regarding my child’s safety. Name of food(s): _______________________________________________________________ Nature of Allergic Reaction: (Please check all that apply.) ⬜ Tingling or itching of the mouth ⬜ Hives ⬜ Itching ­ If so, where? _______________ ⬜ Swelling of lips, face, tongue or throat ⬜ Wheezing ⬜ Nasal Congestion/Trouble Breathing ⬜ Abdominal Pain/Diarrhea ⬜ Nausea/Vomiting ⬜ Dizziness/Lightheadedness ⬜ Fainting ⬜ My child does not have a food allergy. Has your child ever had to use an Epi­Pen because of an allergic reaction? ⬜ Yes ⬜ No Does your child have an Epi­Pen now? ⬜ Yes ⬜ No *If you answered ‘Yes’ to the question above, please contact the campus school nurse to complete additional required documentation. Brenham ISD: ➔ will maintain the confidentially on the information provided. ➔ may share the information to teachers, school counselors, school nurses and other appropriate school personnel in order to take necessary precautions for your child’s safety. Parent Signature: _____________________________________________________________ Date: ____________ Form 6 UPDATED FEBRUARY 2016