New Registration Enrollment Form-bkup

Step of 0:

New Registration Enrollment Form

Student’s Name (First, Middle, Last):

Who is the Primary contact for this student?:

Current custody/guardianship arrangement:

Parents/guardians are together residing at the same residence

Single parent (father and mother are listed on the birth certificate)

Single parent (father is NOT listed on the birth certificate)

Parents/guardians are divorced/separated – joint custody

Parents/guardians are divorced/separated – sole custody

Parents have never been married and have no legal custody papers

Custody/guardianship is transferred by courts

Restricted pickup – legal documentation must be provided

Student is emancipated – legal documentation must be provided

Parent not living with student:

Relationship to student:

Home address:

Mailing Address:

Home phone:

Cell phone:

Work phone:

Email address:

What is your County of Residence?:

What is your Town of Taxation?:

Emergency Contact Information

Name (First, Last):

Relationship to student:

Contact number:

Home Language Questionnaire (HLQ)

If other, specify:

What language(s) is spoken in the student’s home or residence?:

What languages are spoken most of the time to the student in the home or residence?:

What other languages, besides English, does the student speak?:

What languages does the student understand?:

What language(s) does the student read?:

What language(s) does the student write?:

In your opinion, how well does the student understand English?:

In your opinion, how well does the student speak English?:

In your opinion, how well does the student read English?:

In your opinion, how well does the student write English?:

Where was this student born?:

If born outside of the United States, is this student a US citizen?:

Is this student adopted?:

If yes, date of adoption?:

Living Arrangements

Is this student living in temporary housing? If YES, complete section below.:

Complete this only if (1) it reflects your child’s correct living situation: OR (2) you are a student not living with a parent or guardian. Your answer will help school staff with school enrollment and may enable the student to receive additional services.

Check one box if you are living:

In a shelter

With relatives or others due to lack of housing

At a train or bus station, park, or in a car

In a motel/hotel, camping ground, or other similar situation due to the lack of alternative adequate housing

In an abandoned apartment/building

Temporarily house in a shelter awaiting a DCFS permanent foster care placement

Student’s Physician information

Primary Doctor’s Name:

Primary Doctor’s Phone Number:

Dentist’s Name:

Dentist’s Phone Number: