Student Enrollment - Murphy ESD

Murphy Elementary School District

Student Enrollment

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Welcome! Please fill out this enrollment form. You will need to bring specific documents to complete your registration.

School

School *

How did you hear about us?

Student Information

Student Last Name * Student First Name *

Student Middle Name Grade *

Sex * Date of Birth *

State of Birth

Country of Birth

Residency Information

Residential Address * Apt #

City * State * Zip Code *

School History

Has the student attended Murphy District before?

Has the student previously attended school the US?

Attended preschool / Head Start?

Last school attended Grade level at last school

Custody / Living Situation

Student custody Is the current address only temporary?

Is there a court-ordered custody arrangement?

Entry date to the U.S. (if not born in the U.S.)

Status (select all that apply)

Refugee Migrant Immigrant

Demographics

Is the student Hispanic/Latino?

Race (select all that apply)

Asian African American White American Indian/Alaska Native Native Hawaiian/Pacific Islander

Does your family claim American Indian tribal affiliation?

Siblings

Do you have other siblings attending or enrolling in Murphy ESD?

Transportation

Parent/Guardian

Parent/Guardian Name * Home Phone Cell Phone *

Work Phone Email *

Military Service

Active Reserve

Start Date End Date

Additional Parent/Guardian (optional)

Additional Parent/Guardian Name Additional Parent/Guardian Email

Additional Parent Home Phone Additional Parent Cell Phone Additional Parent Work Phone

Relationship to Student (Additional Parent/Guardian Name)

Status and Permissions (Additional Parent/Guardian Name)

Military Service (Additional Parent/Guardian Name)

Active Reserve

Start Date End Date

Emergency Contact

Emergency contacts must be 18 years or older.

Emergency Contact 1

Contact Name * Relation *

Contact Phone *

Emergency Contact 2

Contact Name * Relation *

Contact Phone *

Emergency Contact 3

Contact Name * Relation *

Contact Phone *

Daycare / Afterschool Program Provider

Name Phone Number

No Contact (Student)

Name

Home Language

Primary language spoken at home

What language do people speak in the home most of the time? *

What language does the student speak most of the time? *

What language did the student first speak or understand? *

Services

Has your child ever received special education services or gifted service?

504 Plan Gifted services

Discipline History

Has the student been expelled?

Has the student been suspended more than 10 days?

Has the student been considered for expulsion?

Attest

Enrollment Type * Murphy School District Resident Open Enrollment (non-resident)

I certify that all information provided is true and accurate. *

Typed signature (full name) (optional)