Student Registration Form
Student First Name *
Your answer
Student Last Name *
Your answer
Student Birth Date *
MM
/
DD
/
YYYY
Parents/Guardians Note: Please be prepared to provide proof of age upon request. (Copy of student’s official birth certificate or other certified document.)
Student Gender *
Student Physical Address *
Your answer
Student Mailing Address *
Your answer
Student Ethnicity *
Required
What is the primary language spoken in the home? *
Required
What language did your child FIRST learn to speak: *
Required
What language does your child MOST OFTEN use when speaking to brothers, sisters and other children at home? *
Required
What language does your child MOST OFTEN use when speaking to you and other adults in the home (grandparents, aunts, uncles, guests) *
Required
What language does your child MOST OFTEN use when speaking with friends or neighbors OUTSIDE the home? *
Required
Student currently has: *
Required
Student has Behavioral Concerns (please specify)
Your answer
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