Student’s Name: ____________________________________________ Grade: __________

Primary Contact Phone Number: _____________________________

Country of birth: ____________________________________________

Language spoken at home: ___________________________________

Please answer BOTH part A and B.

Part A.

Is this student Hispanic/Latino?

(Choose only one)

_____

No, not Hispanic/Latino

_____ Yes, Hispanic/Latino

(A person of Cuban, Mexican, Puerto

Rican, Cuban, South or Central American, or other Spanish culture

or origin, regardless of race.)

Part B.

What is the student’s race?

(

Choose one or more)

_____

American Indian or Alaska Native

(A person having origins

in any of the original peoples of North America including Mexico,

South America, and Central America, and who maintains tribal

affiliation or community attachment.)

_____

Asian

(A person having origins in any of the original

peoples of the Far East, Southeast Asia, or the Indian subcontinent

including, for example, Cambodia, China, India, Japan, Korea,

Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.)

_____

Black or African American

(A person having origins in any

of the black racial groups of Africa.)

_____

Native Hawaiian or Other Pacific Islander

(A person

having origins in any of the original peoples of Hawaii, Guam,

Samoa, or other Pacific Islands.)

_____

White

(A person having origins in any of the original

peoples of Europe, the Middle East, or North Africa.)

Parent/Guardian Signatur e: ______________________________ Date: ________________