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Racial & Ethnic Identification
Student's name
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First Name
Middle Initial
Last Name
Student's date of birth
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Month
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Day
Year
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Is the student Hispanic, Latino, or of Spanish origin? Hispanic, Latino, or of Spanish origin means a person of Cuban, Mexican, Puerto Rican, Central or South American, or other Spanish culture or origin, regardless of race.
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Yes, Hispanic
No, not Hispanic
Select one or more races from the following five racial groups. Please check all boxes that apply to your child; check at least one box.
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AMERICAN INDIAN OR ALASKA NATIVE: A person having origins in any of the original peoples of North and South America (including 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.
NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
BLACK OR AFRICAN AMERICAN: A person having origins in any of the Black racial groups of Africa.
WHITE: A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
Parent/Guardian's signature
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Parent/Guardian's name
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First Name
Last Name
Today's date
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Month
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Day
Year
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