PEOTONE COMMUNITY UNIT SCHOOL DISTRICT 207-U ENROLLMENT CARD

Demographic Information:

Grade in School 2017-2018: _______________

Name of Student:

___ Last Name

Home Address: Mailing Address:

Full First Name

Full Middle Name

Nickname/ Goes By

____________________________________________

____________________, IL

_____________

Street, Route, Box Number

City

Zip Code

____________________________________________

____________________, IL

_____________

Street, Route, Box Number

City

Zip Code

Primary Telephone:

___ Parent E-Mail Address:

___

Student Resides With:

___ Relationship to Student:

_

Has student ever attended school in Peotone CUSD 207U? _______ Yes _______ No If yes, what school(s) and approximate dates? __________________________________________________________________________ Ethnicity Code: ________________

Gender: (M/F) _________________

Date of Birth: _____/_____/________

- See separate Ethnicity form required by the State of Illinois 01-American Indian/Alaskan Native 02-Asian/ Pacific Islander 03-Black/ African American 04-Hispanic 05-White/ Caucasian 06-Multiracial/Ethnic

Special Services: My child has

________ IEP

________ 504 Plan

Parents/Guardians: Name of Father or Guardian 1: ________________________________________ Day Phone: ____________________________________________

________ Speech Services

Other: ________

Employer: ____________________________

Cell Phone: _________________________________________

Father/Guardian 1 Address (if different from above): ______________________________________________________________ Name of Mother or Guardian 2: _______________________________________ Day Phone: ____________________________________________

Employer: ____________________________

Cell Phone: _________________________________________

Mother/Guardian 2 Address (if different from above): ______________________________________________________________ Non-Guardian Emergency Contacts:

Please verify we have 2 contacts in case of an emergency.

Name:

____________________________________________ Phone:

__________________

Phone 2: __________________

Name:

____________________________________________ Phone:

__________________

Phone 2: __________________

Sibling Information: Sibling 1: Name: _____________________________________________________________ Grade: ________________________ Sibling 2:

Name: _____________________________________________________________ Grade: ________________________

Sibling 3:

Name: _____________________________________________________________ Grade: ________________________

Medical Information: Doctor:

Phone:

Dentist:

Phone:

Preferred Hospital:

If I cannot be reached in case my son or daughter needs emergency medical care because of illness or injury while at school, please take him or her to my family physician, if possible. If this is not possible, then to any other physician who is available or to the nearest hospital.

Primary Insurance Carrier: ______________________________________

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Emergency Closing of School: When school is cancelled before students arrive, the number to call: When school is closed during the school day, the number to call: ~ my child will:

(Take assigned bus, be picked up, walk or ride bike)

Permission to Photograph: Throughout the school year, photographs and/ or videos are taken of students during various classroom activities, field trips, assemblies, athletic or special events. Photos may be released to the media for publication or posted on the Internet along with student names. We are proud of our students and of our programs and would like to highlight them. Yet, we wish to respect your wish should you prefer that your student not be identified. Please indicate your choice on this permission form, and we will make every effort to comply with it. _____ YES _______ NO

I give permission for my child to be photographed or videotaped during school-related activities, and for the photos and names

to be released to the media and/or on the district websites.

Parent / Student Handbook Verification: It is our desire that parents/guardians become involved in their child’s school career. By reading the information presented in the handbook and by reviewing it with their child, both parents/guardians and students will be able to better understand the policies and procedures of the schools in Peotone CUSD 207U. Furthermore, being aware of this information can help establish a positive and successful school career. It is the responsibility of the parents/guardians to review the policies and procedures of the appropriate school with each of their children. The Parent / Student Handbook can be found online at www.peotoneschools.org under the Parent Information tab. Printed copies can be requested from the school office your child attends.

⎕

(please check to confirm) I verify that I have read (or will read) the 2017-2018 Parent Student Handbook for the school(s) my child attends.

_______________________________________________________________________________________________________________________________________________

_________________________________________________________________________

Signature of Parent / Guardian

Date

Rev. 3.08.17