Fort Cobb

Please Fill Out The Fort Cobb-Broxton Public Schools Student Enrollment Questionnaire. (One form required per household) Below

Fort Cobb-Broxton Public Schools Student Enrollment Questionnaire

We only need one form per family.

Student Name:

Date of Birth:

MALE OR FEMALE:

Reaquired field: Male

Reaquired field: Female

GRADE:

SCHOOL NAME:

Your child may be eligible for additional educational services through Title X, Part C McKinney-Vento Assistance Act. Eligibility can be determined by completing this questionnaire.

Where are you and your family currently living? Please check one of the boxes below

If you do not rent/own your own home or apartment, please check one of the boxes below:

Reaquired field: Temporarily with another family member or friend until we can locate affordable housing

Reaquired field: In an emergency or transitional shelter

Reaquired field: In a vehicle, park, campground, or on the streets

Reaquired field: In a house, building, or trailer WITHOUT running water or electricity

Reaquired field: In a hotel or motel

Reaquired field: Alone or in different locations, without an adult serving as a caregiver

Reaquired field: Wherever I can find a place to stay at night

Reaquired field: Rent/own my own home or apartment. STOP: If you checked this box that you rent/own your own home or apartment skip to the bottom of the page, sign the form, and then submit to school personnel. If you do not rent/own your own home or apartment, please continue to the next section.

Reaquired field: Other

If you checked a box other than rent/own your home, in the space below please list all children currently living with you who attend Fort Cobb-Broxton Public Schools.

FIRST & LAST NAME OF STUDENT:

MALE OR FEMALE:

Male

Female

DATE OF BIRTH:

GRADE:

SCHOOL NAME:

FIRST & LAST NAME OF STUDENT:

MALE OR FEMALE:

Male

Female

DATE OF BIRTH:

GRADE:

SCHOOL NAME:

FIRST & LAST NAME OF STUDENT:

MALE OR FEMALE:

Male

Female

DATE OF BIRTH:

GRADE:

SCHOOL NAME:

FIRST & LAST NAME OF STUDENT:

MALE OR FEMALE:

Male

Female

DATE OF BIRTH:

GRADE:

SCHOOL NAME:

Would you like to be contacted by an employee of the school to discuss additional educational services that may be available to your child?

Yes

The undersigned certifies that the information provided is correct and accurate.

Parent/Guardian or Adult Caring for the Student:

Relationship to Student:

Signature:

Street Address:

City:

State:

Zip:

Phone Number:

Email:

Email a copy to

optional

Required Fields

FORT COBB BROXTON SCHOOLS

Fort Cobb-Broxton Public Schools Student Enrollment Questionnaire. (One form required per household)