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Ben Franklin Middle School New Student Information 2021-2022
Please complete and submit the information below. Based on the information you provide here, you will be contacted for an appointment to enroll your student.
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* Indicates required question
STUDENT'S Last Name
*
Your answer
STUDENT'S First Name
*
Your answer
Preferred Name
Example: Michael - Mike
Your answer
Gender
*
Female
Male
Student's Date of Birth
*
MM
/
DD
/
YYYY
Student's Birth City:
*
Your answer
Student's Birth State:
*
Your answer
Ethnicity
*
Check all that apply
Hispanic/Latino Ethnicity
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Required
Student's House Number
*
Example: 305
Your answer
Student's Street Name
*
Example: Franklin St - please use abbreviation Ave, Ct, Dr, Ln, Pkwy, Pl, Rd, St, Ter
Your answer
Apartment
Example: 1/A
Your answer
Student's Zip Code
*
46383
46385
Phone number where you prefer to be contacted for this appointment
*
Enter Primary Number In This Format: 219-531-3000
Your answer
Select Phone Type
*
Cell
Landline
Custodial Parent Last Name, Mother's First Name/Father's First Name
*
Example: Smith, Jane/John
Your answer
Custodial Parent Relationship
*
Father/Mother
Father Only
Mother Only
Father/Stepmother
Mother/Stepfather
Legal Guardian
Other
Custodial Parent's Email Address
*
Type: 'None' if you do not have email
Your answer
Non-Custodial Parent's Email Address
Your answer
Mother's Last Name
Your answer
Mother's First Name
Your answer
Mother's Primary Contact Number
*
Enter Primary Number In This Format: 219-531-3000
Your answer
Select Phone Type
*
Cell
Landline
Father's Last Name
Your answer
Father's First Name
Your answer
Father's Primary Contact Number
*
Enter Primary Number In This Format: 219-531-3000
Your answer
Select Phone Type
*
Cell
Landline
Is Engish the primary language spoken at home?
*
Yes
No
List other language(s) spoken at home
Your answer
Does your child have any special needs
*
Yes
No
Has your child been evaluated or received services from Porter County Educational Services?
*
Please let us know if they attend SELF now or have in the past
Your answer
Describe any special needs information
Your answer
Does your child have siblings at this or any other VCS school?
*
Yes
No
Names and Grade of Siblings
Sibling Name: Last, First and Grade
Your answer
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