Download Denver Public Schools

Denver Public Schools
Pre-Enrollment Information Form
This 4 page form is required information if your child is not currently attending a Denver Public School
(DPS) and you are requesting a DPS school assignment for school year 2010-2011.
The following information and documentation must be provided when submitting this Pre-Enrollment form:

Proof of Birth: copy of birth certificate, hospital record, non-U.S. passport, or baptismal record.

Proof of Residence: copy of lease agreement, utility bill (showing service address), cable bill, Denver
County tax notice, warranty deed, bill of sale, settlement statement from closing or a signed contract
stating your name, closing date and property address.

Home Language Questionnaire: a separate form given to you from the school secretary.
*Other documentation will be requested at the time of Registration*
(You will need to complete a registration verification packet for the school your child will be attending.)
Please note that due to new Federal requirements for reporting race/ethnicity the questions regarding
race/ethnicity have changed.
*Early Childhood Education (ECE) or Kindergarten children new to Denver Public Schools do not need to fill out this
form. There are separate applications for ECE/K – please ask your school secretary for an application.*
Denver Public Schools Pre-Enrollment Information Form 2010
Denver Public Schools
Pre-Enrollment Information Form
Page 1 of 4
Student Census/Enrollment Information
Please print
Student’s Full Legal Name: ___________________________________________________________________________________________________
Last
First
Middle
Grade: _______
Gender: M  F 
Birth date: _____________________________
Month
Day
State/Country of Birth: ________________________
Year
Please provide verification of birth date to the school – birth certificate, baptismal record, hospital record showing birth, or copy of non-US passport
Race/Ethnicity
1 What is your child’s ethnic background:
Is child Hispanic or Latino?
❏ Yes
❏ No
You must answer question 1 and question 2. Question 1 is about ethnicity, not race.
No matter what you selected in question 1, please continue to answer the following question by selecting one or more races.
2
Which of the following groups describes your child's
race? (Select all that apply)
❏ American Indian or Alaskan Native
❏ Native Hawaiian or other Pacific Islander
❏ Asian
❏ Caucasian/White
❏ Black or African American
Failure to answer race and ethnicity questions will result in an observer identifying for you.
This question below is similar to the ones you answered above. While it may seem repetitive, it is important that you respond to this question.
3
Which of the following describes your child's race or
ethnicity? (Choose only one)
❏ American Indian or Alaska Native
❏ White (not Hispanic)
❏ Black (not Hispanic)
❏ Asian or Pacific Islander
❏ Hispanic
Previous School Information
Has the student attended another DPS School? Yes  No School: ___________________________________ Grade: _______ School Year: __________
Last School Attended Outside the Denver Public Schools
School: _______________________________________ Grade: ________ School Year: ______________ City: _____________ State: _____________
List the first time the student was enrolled in any school in the US (including preschool and kindergarten)
Month
Year
Grade (pk-12)
Month
Year
Grade (1-12)
Month
Year
Grade (1-12)
List the most recent time the student was enrolled in any school in the US (NOT including preschool and kindergarten)
List the most recent time the student was enrolled in a Colorado public school (NOT including preschool and kindergarten)
Is your child presently under an expulsion order from any other school district?
Is your child presently under consideration for expulsion?
Yes  No 
Yes  No 
Is your child presently involved in the Juvenile Justice system?
Yes  No 
I attest under penalty of perjury that all the information provided is true to the best of my knowledge.
Parent/Guardian Signature: _________________________________________________ Date: ______________________
Denver Public Schools Pre-Enrollment Information Form 2010
Denver Public Schools
For Office Use Only:
Student ID _______________
School __________________
Pre- Enrollment Information
Page 2 of 4
Student Name: _________________________________
ELA Information
Please complete the Home Language Questionnaire included in this packet.
If one IS NOT included, please contact the school secretary.
Special Services Information
Is your child receiving special education services?
Yes  No 
Does your child have a current 504 plan?
Yes  No  if yes, please indicate if related to: Academics Health 
Is your child in any Gifted/Talented programs?
Yes  No  if yes, please list____________________________________________________
Does your child have any medical alerts?
Yes  No  if yes, please explain on page 5.
Household Information
Please print
Please provide verification of address to the school
i.e. –current utility bill, cable bill, current rental agreement, warranty deed, bill of sale, settlement statement from closing, current Denver County tax notice,
or signed contract stating your name, closing date and property address. If address is not verifiable additional documentation may be requested.
Contact Information to be used for Automated Messenger
Household Telephone: ___________________________
High Priority Attendance Behavior General

Email Address:_______________________________________
High Priority Attendance Behavior General

Residence Address:
City:
State:
Zip:
State:
Zip:
Mailing Address:
City:
Student Lives With: Please check one box
Both Parents

Foster Parents 
Mother Only 
Relatives 
Father Only 
Mother/Stepfather 
Father/Stepmother 
Other 
Note: When a student does not reside with both parents, additional information must be on file so that the school can determine who is responsible for the
student. If there are applicable legal documents, such as custody papers, a copy should be provided to the school. If the arrangement is less formal another
registration packet will need to be submitted.
I attest under penalty of perjury that all the information provided is true to the best of my knowledge.
Parent/Guardian Signature: _________________________________________________ Date: ______________________
Denver Public Schools Pre-Enrollment Information Form 2010
Denver Public Schools
For Office Use Only:
Pre-Enrollment Information Form
Student Emergency Information
Page 3 of 4
Student ID _______________
School __________________
Student Name: _________________________________
Parent/Guardian Contact Information
Emergency Contact # 1  2  3  4  (check only one)
Gender:
M  F 
Legal Guardian
Name: ___________________________________________________________ Relationship to Student: ____________________
Yes  No 
Residence Address: __________________________________________________________________________________________________________
Contact information to be used for Automated Messenger
Check the Boxes that Apply
High Priority Attendance Behavior General
 
Work Telephone:
High Priority Attendance Behavior General

Cell Telephone:
High Priority Attendance Behavior General

Email:
High Priority Attendance Behavior General

Other Telephone:
Ext.
Notes: ______________________________________________________________________________________________________
Parent/Guardian Contact Information
Emergency Contact # 1  2  3  4  (check only one)
Gender:
M  F 
Legal Guardian
Name: ___________________________________________________________ Relationship to Student: ____________________
Yes  No 
Residence Address: __________________________________________________________________________________________________________
Phone Numbers to be used for Automated Messenger
Check the Boxes that Apply
High Priority Attendance Behavior General
 
Work Telephone:
High Priority Attendance Behavior General

Cell Telephone:
High Priority Attendance Behavior General

Email:
High Priority Attendance Behavior General

Other Telephone:
Ext.
Notes: ______________________________________________________________________________________________________
Denver Public Schools Students Living in the Household
Last Name
First Name
Middle Name
Gender
Parent/Guardian Relation to Student
Parent/Guardian #1
Parent/Guardian #2
DPS School Attending
I attest under penalty of perjury that all the information provided is true to the best of my knowledge.
Parent/Guardian Signature: _________________________________________________ Date: ______________________
Denver Public Schools Pre-Enrollment Information Form 2010
For Office Use Only:
Student ID _______________
School __________________
Denver Public Schools
Pre-Enrollment Information Form
Student Emergency Information
Page 4 of 4
Student Name: _________________________________
Other Emergency Contact Information
Emergency Contact # 1  2  3  4  5  6  (check only one)
Name: ________________________________________________________ Relationship to Student: ___________________________
Household Telephone: _____________________ Work Telephone: _____________________Cell Telephone: ____________________
Notes: __________________________________________________________________________________________
Emergency Contact # 1  2  3  4  5  6  (check only one)
Name: ________________________________________________________ Relationship to Student: ___________________________
Household Telephone: _____________________ Work Telephone: _____________________Cell Telephone: ____________________
Notes: __________________________________________________________________________________________
I attest under penalty of perjury that all the information provided is true to the best of my knowledge.
Parent/Guardian Signature: _________________________________________________ Date: ______________________
Denver Public Schools Pre-Enrollment Information Form 2010