MT. VERNON PUBLIC SCHOOL 17 – 3
Personal Information Form 2018-2019
Email address *
1st Student Name:
Your answer
Age:
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Sex:
Student Cell Number:
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Place of Birth: (City & State)
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Date of Birth:
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/
DD
/
YYYY
Answer BOTH questions: (Required by USDOE for data collection relative to ESSA Act.)
Is this student Hispanic or Latino? (Choose only one)
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What is the student’s race?
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Does this child have any physical/medical problem?
Specify if Yes:
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