MT. VERNON PUBLIC SCHOOL 17 – 3
Personal Information Form 2018-2019
1st Student Name:
Student Cell Number:
Place of Birth: (City & State)
Date of Birth:
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
Black or African American
Native Hawaiian or Pacific Islander
Does this child have any physical/medical problem?
Specify if Yes:
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This form was created inside of State of South Dakota K-12 Data Center.
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