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Race / Ethnicity Reporting Form

Student's Grade:_______

Student's Last Name:______________________________

Student's First Name:______________________________

Race/Ethnicity Reporting

Northwest Allen County Schools

The federal government is changing the way schools report race and ethnicity information, so all school records must be updated. Please answer both of the questions below.

Part 1: Ethnicity

Is this individual 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 2: Race

What is the individual's race? (Choose one or more)

___ American Indian or Alaska Native: A person having origins in any of the original peoples of North America and maintaining cultural identification through tribal affiliation or community recognition.

___ 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 Name: _________________________________________

Parent/Guardian Signature:_______________________________________