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MT. VERNON PUBLIC SCHOOL 17 – 3
Personal Information Form 2023-2024
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Student Name
Your answer
Student Age
Your answer
Sex:
Male
Female
Student Cell Number:
Your answer
Place of Birth: (City & State)
Your answer
Date of Birth:
MM
/
DD
/
YYYY
Answer BOTH questions: (Required by USDOE for data collection relative to ESSA Act.)
Is this student Hispanic or Latino? (Choose only one)
No, not Hispanic or Latino? (Proceed to question #2)
Yes, Hispanic or Latino
What is the student’s race?
American Indian or Alaskan
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
Does this child have any physical/medical problem?
Yes
No
Specify if Yes:
Your answer
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