Sunrise Middle School Enrollment/Registration

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Demographic Information

Student's Last Name *

Student's First Name *

Student's Middle Initial

Entering Grade Level *

Student's Date of Birth *

YYYY

Student's Gender *

Female

Male

Is the student Hispanic or Latino? *

Yes

I don't know

Student's Ethnicity *

Chinese (201)

Japanese (202)

Korean (203)

Vietnamese (204)

Indian from India (205)

Laos (206)

Cambodian (207)

Hmong (208)

Other Asian (299)

Hawaiian (301)

Guamanian (302)

Samoan (303)

Tahitian (304)

Filipino/Filipino-American (400)

Other group from the Pacific Islands (399)

Black or African American (600)

White (Person whose origin is from Europe, North Africa, or Middle East (700)

Native American or Native Alaskan (A person whose origin is from the native people of North, Central, or South America (100)

Choose not to answer (999)

Required

Student's address

Street *

Apt. Number ( Leave blank if not applicable)

City *

State *

Zip code *

Home phone *

Student Email

SJ Unified Resident? *

Yes

Student District of Residence *

Out of San Jose Unified SD

Mt. Pleasant Elementary

Evergreen Elementary

Hayward Unified SD

Orchard Elementary

Franklin McKinley Elementary

Oak Grove Elementary

Berryessa Union SD

Alum Rock Union SD

San Jose Unified SD

Other:

Required

Student's Former School *

Student's Mother Information

Last Name

First Name

Phone number

Student's Father Information

Last Name

First Name

Phone Number

Student's Birth State *

Student's Birth Country *

If the student was not born in the USA, when did the student first enroll in a school in the USA?

YYYY

Parents' Highest Educational Level *

Did not graduate from high school

Some college (AA degree)

Graduated from a 4-year university

Graduated from high school

Post-graduate degree

Required

Residence *

Single family

Shared housing

Decline to state

Address of parents or legal guardians (if different from the student's address)

Student social security number *

Has the student been enrolled in a school in the US for less than three years? *

Yes

The student lives with *

Only the mother

Only the father

Both the mother and father

Father / Stepmother

Mother / Stepfather

Group Home / Foster Care

Other:

Primary language spoken at home by the student:

English

Spanish

Other:

Clear selection

Student's first language *

Language student uses most often at home *

Language the parents speak most often *

Has your child ever taken the California English Language Development Test (CELDT)?

Yes

I don't know

Clear selection

Do you have a “Caregiver Affidavit”. Form completed? If there is an agreement of legal custody regarding the student, please select: (If student is not to be released to both parents, a copy of the custody papers must be on file at the school.)

Joint custody

Individual custody

Guardian

Emergency Contacts

Emergency contact #1 Full name *

Emergency contact #1 Phone number *

Emergency contact #1 Relationship *

Emergency contact #2 Full name *

Emergency contact #2 Phone number *

Emergency contact #2 Relationship *

Emergency contact #3Full name *

Emergency contact #3 Phone number *

Emergency contact #3 Relationship *

Medial Information

Medical insurance name *

Group/Id number *

Doctor full name *

Phone number *

Dentist full name *

Phone number *

Does your student have any allergies? *

Yes

If yes, please provide the type of allergy that your student has and provide the specific actions that need to be taken if your student suffers an allergic reaction:

Does your student have any other health problems of which the school should be aware of? *

Yes

If yes, please describe:

Does your student wear glasses or contacts? *

Yes

If yes, only in the classroom or all day?

Classroom only

All day

Clear selection

If activities should be limited in any way, please explain:

Please indicate if your child has had any of the following conditions: *

Meningitis

Polio

Hepatitis

Diabetes

Joint pains

Ear infections

Asthma

Heart disease

Sleepwalking

Rheumatic fever

Scarlet fever

Whooping cough

Fainting spells

Epilepsy

Tires easily

Frequent colds

Eczema

Mumps

Chicken pox

Measles

German measles

Sore throats

Headaches

Convulsions

Nightmares

Nosebleeds

Required

Is your child on a medication regimen? If YES and medication needs to be administered during schools hours, then Sunrise Middle School will require a doctor’s note. *

Yes

If YES, what is the condition?

If YES, what is the dosage?

If YES, what is the medication?

If YES, what is the physician's name?

If YES, what is the physician's phone?

Is your student allergic to any medications?

Yes

Clear selection

If yes, please list medicine(s) and type of reaction:

Does your student take any medication (either over-the-counter or prescription) on a regular basis? *

Yes

If yes, please list:

Special Education Inquiry Form

Does your child have an IEP (Individualized Education Program)? *

Yes

Does your child have a 504 Plan? *

Yes

Does your child have a Psychological Report? *

Yes

Does your child have a Speech Report? *

Yes

Has your child been enrolled in Special Day Class? *

Yes

Has your child been enrolled in a Resource Specialist Program (RSP)? *

Yes

Has your child been identified as needing any other special education services not listed above? *

Yes

If yes, please explain

If you answered YES to any of the questions listed above, please provide the name of the school and your student’s grade when your student receive his/her most recent IEP, 504 Plan, Psychological Report, or Speech Report, or the name of the most recent school where your student was enrolled in Special Day Class, RSP, or any other special education services.

Name of former school

Grade level

Former school address (street city State, Zip code)

Former school phone

Former school fax

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