Welcome to The Nextdecade Inc.

+ (805) 512-1843
[email protected]

Monday-Friday 9:00am-3:00pm
Sunday Closed

FAMILY INTERVIEW

INITIAL SUMMARY WORKSHEET

(List needed skills mentioned by family for increased independence and participation in each area)

Selfcare, Independent Living
Recreation, Leisure.
Vocational
Community Access, Motor Skills
Communication
Social, Emotional
Functional Academics

STUDENT REGISTRATION FORM INITIAL ENROLLMENT

(MATRICULACION INICIAL)

PLEASE COMPLETE BOTH SIDES IN BLUE OR BLACK INK (POR FAVOR COMPLETE AMBOS LADOS CON TINT A AZUL 0 NEGRA)

Student Name (Estudiante)
D.O.B.
Gender (genero)    Female       Male

Student Ethnicity (Origen etnico. Marque uno)

Hispanic or LaUno (Una perscna de Cuban, Mexican, Puerto Rican, South or Central American, u otro origen o culture hispana sin importer Ia raza)

Not Hispanic or LaUno

Student Race (Raza del estudiante. Par favor marque haste 5 categories raciales). The above part of the quesUon is about ethnicity, not race. No matter what you selected above, please continue to answer the followinq by markinq one or more boxes to indicate what you consider your race to be.

American Indian or Alaskan Native I Indio Americana o Nafivo de Alaska (100) (Persons having origins in any of the original people of North, Central or Soutll America/ tener origen en cualquier pueblo originario de America del Norte, Central o del Sur )

Chinese / Chino (201)

Japanese / Japones (202)

Korean / Coreano (203)

Vietnamese / Vietnamita (204)

Asian Indian / Indio Asiatica (205)

Laotian / Lao (206)

Cambodian / Camboya (207)

Hmong (208)

Other Asian / Otro Asiatica (299)

Hawaiian (301)

Guamanian /Guaymeno (302)

Samoan (303)

Other Pacific Islander / Otras is/as del Pacifico (399)

Filipino/Filipino American (400)

African American or Black I Africano Americana o Negro (600)

White / Blanco (700) (Persons having origins in any of the original peoples of Europe, North Africa, or the Middle East / Tener origen en cualquier pueblo originario de Europa, Africa del Norte o Medio Oriente)

Tahitian / Tahitiano (304)

HOME LANGUAGE SURVEY (Encuesta de ldioma en Casa)

1. Which language did the student learn when he first began to speak?(, Cual idioma aprendi6 su hijola primero?

2. What language does the student speak most frequently at home?(, Que idioma usa su hijola mas frecuente en casa?

3. What language is most spoken by the adults at home? t, Que idioma us an mas frecuente los adultos en cas a?

4. What language is most often spoken to the student by the parents? 1, Que idioma es usado mas frecuente por los padres con el estudiante?

Address: (Domicilio)
Phone (Telefono)
Cell Phone (celular)
Student Bom (EI estudiante nacio)
Citizenship (Ciudadania)
First Enrolled in US (Primera vez que se inscribio en US)
First Enrolled inCA (Primera vez que se inscribio en CA)

STUDENT LIVES (EI estudiante vive en)

In a single family permanent residence (house,apartment, condo, mobile home) / En una residencia permanente para una familia (casa, apartamento, condo,casa remo/que)

Doubled-up (sharing housing with other families/ individuals due to economic hardship or loss) / Multiplicada (compartiendo Ia vivienda con otras familiaslindividuos debido a dificultad o perdida econ6mica) ( 11)

In a shelter or transitional housing program / En un albergue o programa de vivienda transitoria (10)

In a foster home I En un hagar de crianza

Agency / Agencia:

In a motel/hotel (09)

Unsheltered (car/campsite) / A Ia intemperie (cochelcampamento) ( 12)

Licensed Child Institute 1/nstituto infantil certificado

Other (please specify) I Otro (especifique) (15)

PARENTAL INFORMATION (Informacion de los padresltutores)

Student lives with (EI estudiante vive con):    Father (Padre)      Mother (Madre) )      Guardian (Tutor)

Father's Information (Informacion del padre):

Father's Name (Nombre del padre)
Occupation ( Ocupacion)
Place of Work (Lugar de trabajo)
email ( correspondencia electr6nica)
Work Phone (Te/efono del trabajo)
Home Phone (Telefono del hagar):
Address: (Domicilio)
Father's Education (Educaci6n del padre):    Not a High School Graduate (No graduado de Ia preparatoria)      High School Graduate (Graduado de Ia preparatoria)      Some College (A/go de colegio)      College Graduate (Graduado del colegio)      Graduate School (Escue/a de bachillerato)      Decline to state (Prefiere no responder)
Father's primary language (ldioma primario del padre)

Mother's Information (lnformacion de Ia madre):

Mother's Name (Nombre de Ia madre)
Occupation ( Ocupacion)
Place of Work (Lugar de trabajo)
email ( correspondencia electr6nica)
Work Phone (Te/efono del trabajo)
Home Phone (Telefono del hagar):
Address: (Domicilio)
Mother's Education (Educaci6n del padre):    Not a High School Graduate (No graduado de Ia preparatoria)      High School Graduate (Graduado de Ia preparatoria)      Some College (A/go de colegio)      College Graduate (Graduado del colegio)      Graduate School (Escue/a de bachillerato)      Decline to state (Prefiere no responder)
Mother's primary language (ldioma primario de Ia madre)

Names of students and contacts other than mother and father in the student's household I Nombres de otros estudiantes y contactos que no sean los padres que viven en Ia casa:

First Name / Nombre
Last Name / Apellido
Relationship Type / Parentesco
Contact Type / Clase de Contacto
Gende / Genera
Birthdate / Fecha de Nacimento

Names of contacts not living with student I Nombres de los contactos que no viven con el estudiante:

First Name / Nombre
Last Name / Apellido
Relationship Type / Parentesco
Contact Type / Clase de Contacto
Phone / Telefono

MEDIA PERMISSION (Permiso para los medias de comunicacion)

I approve having photographs and video of my child taken for parents/guardians, school records and educational purposes. (Apruebo a que le tomen fotografias y video ami hijo/a para los padresltutores, expedientes escolares, y con fines educativos.)     Yes/Si    No

I approve having photographs and video of my child taken for use in news coverage, VCOE websites and social media platforms, and other informational materials for the public.(Apruebo a que le tomen fotografias y video a mi hijola para coberturas de noticias, sitios web de VCOE y plataformas de medias sociales, y otros materiales informativos parael p(Jblico.)        

EDUCATIONAL RIGHTS (Derechos educativos)

Educational rights for this student are held by (estan a manos de):

As documented by I Como se document6 por:

Dated I Fechado:   

I have reviewed this fonm for accuracy and all the information is correct I He revisado este formulario para exactitud y todo esta correcto.

I have made all necessary changes to this fonm (to ensure changes are noted, please use colored ink or highlight changes) I He hecho todos los cambios necesarios (para asegurar que los cambios se noten, favor de user tinta de otro color o resalte /os cambios).

Parent Signature (Firma del padre /tutot)
Date (Fecha)

For Office Use Only

StudentiD#
Date Enrolled
District of Residence
Enrollment Verified

Providing Daily Support for Young Adults with Disabilities Beyond School Age (22+)

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