ED Form-02471-01 LAB

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ED Form-02471-01 LAB
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  Revised 9/2013 (over) Page 1 Early Learning Services 1500 Highway 36 West Roseville, MN 55113-426 Early Education Student ED-02471-XX   Draft 2014-2015 School Year Directions to district staff: 1. Use the resources at located at Early Education Student for more information on how to complete this reporting process. 2. The User Manual at the same website details the valid responses for each element below. 3. The Parent Questionnaire for Early Education Student may be distributed to parents to gather their voluntary responses to the following categories: education background, household income, family size and employment status. Administrative data sets may provide the remaining details. STUDENT *State Student ID:________________________________ *Name (Last*):___________________________________ *Name (First*):_____________________________ Name (M.I.):______ Name (Suffix): *Date of Birth ( MM/DD/YYYY ): *Gender (M/F): *School Year (YYYY-YYYY): *Immunizations Up to Date (Y/N): Ethnicity: Hispanic/Latino (Y/N): Race: Check all that apply: American Indian Asian Black Native Hawaiian White  Migrant (Y/N): Primary Language: McKinney-Vento Homeless (Y/N): PROGRAM REGISTRATION *District Number: *District Type: *Program Name: Check One: SR ECFE ECFE/ABE SR/ABE Other *Registration Date: *Count of Classes: *Fee Status: Check One: Full Fee Reduced Fee No Fee  *Funding Source: Check One: Parent Fee SR ECFE ECSE Head Start Early Head Start Title 1 Non-DHS funded child care Other district Other County Scholarship (State/Federal) Scholarship (Community) Private Foundation Grant *Special Needs or Delay NOT Eligible for Special Education: Check One Below: Child has special needs, but is not eligible for special educational services Child has no special needs or is eligible for special educational services    Revised 9/2013 Page 2 REGISTERING PERSON *Name (Last, First): Date of Birth (MM/DD/YYYY): *Type: Check One: Foster Father Father Foster Mother Mother Guardian  –  Male Guardian  –  Female Other Relative  –  Male Other Relative  –  Female Education Background: Check One: Doctoral Degree Mast er’s Degree Bachelor’s Degree    Associate’s Degree Some College, but no degree High School Diploma Some High School, no diploma Some elementary and middle school, none beyond eighth grade  Employment Status: Check One: Employed more than 25 hrs/week Employed less than 25 hrs/week Unemployed, seeking employment Unemployed, not seeking employment  Yearly Household Income: Number of People in Household: *Receiving Interpreter Assistance (Y/N): *Classroom Volunteer Type: Check One: Not Volunteering Classroom volunteer Parent Advisory Council Volunteer Other as district identifed  * Required element
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