STUDENT ENROLLMENT FORM

ID #

CARY-GROVE HIGH SCHOOL

YR OF GRAD

COUNSELOR

GRADE

DATE OF APPROVAL

ENTERED BY

GENERAL INFORMATION STUDENT’S LEGAL NAME: (AS SHOWN ON BIRTH CERTIFICATE) LAST NAME

FIRST NAME

DATE OF BIRTH

MIDDLE

MALE

FEMALE

LAST SCHOOL ATTENDED

CITY, STATE

STUDENT’S BIRTH CITY, STATE

BIRTH COUNTRY

ENROLLING GRADE

PARENT/GUARDIAN 1: (THE PERSON WITH WHOM THE STUDENT LIVES) LAST NAME

FIRST NAME

RELATIONSHIP TO STUDENT

ADDRESS

HOME TELEPHONE

CITY

ZIP

CELL

EMAIL ADDRESS

WORK

PARENT/GUARDIAN 2: (THE PERSON WITH WHOM THE STUDENT LIVES) LAST NAME

FIRST NAME

RELATIONSHIP TO STUDENT

ADDRESS

HOME TELEPHONE

CITY

ZIP

CELL

EMAIL ADDRESS

STUDENT LIVES WITH:

WORK Mother Only

Father Only

Both Parents

Mother/Stepfather

Father/Stepmother

Guardian

SIBLINGS ATTENDING CARY-GROVE:

SECOND FAMILY INFORMATION (NON-CUSTODIAL) LAST NAME

FIRST NAME

ADDRESS

RELATIONSHIP TO STUDENT HOME TELEPHONE

CITY

ZIP

CELL

EMAIL ADDRESS

WORK

MILITARY INFORMATION (Optional - per IL Statute 105ILCS 5/22-70) Does the student have a parent/guardian currently serving in the armed forces of the United States and who is either deployed to active duty or expects to be deployed during the school year? Yes No Deployment Start Date: End Date:

RACE CODES What is the student’s race? Select one or more. AMERICAN INDIAN OR ALASKAN NATIVE: Origin in any of the original people of North and South America, including Central America, and who maintains tribal affiliation or community attachment. ASIAN: Origin in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including for example, Cambodia, Pakistan, The Philippine Islands, Thailand, and Vietnam. BLACK OR AFRICAN-AMERICAN: Origin in any of the black racial groups of Africa. NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER: Origin in any of the original people of Hawaii, Guan, Samoa, or other Pacific Islands. WHITE: A person having origins in any of the original people of Europe, the Middle East, or North Africa.

ETHNICITY Hispanic or Latino

HOME LANGUAGE SURVEY Is English the primary method of communication at home? Yes No If no, does the student need additional support in English? Yes Does anyone in your home speak a language other than English? Yes No If yes, insert language code as referenced on next page: Does the student speak a language in the home other than English? Yes No If yes, insert language code as referenced on next page: Has the student received ELL/ESL or bilingual services before? Yes No If yes, insert language code as referenced on next page:

SPECIAL SERVICES RECEIVED Has your child ever received special education services? Does your child have a current IEP? Does your child have a current 504 Plan?

SIGNATURE OF PARENT/GUARDIAN: PRINT NAME OF PARENT/GUARDIAN:

Yes Yes Yes

No If yes, what grades? No If yes, please attach a copy of the most recent IEP. No If yes, please attach a copy of the most recent 504 Plan. DATE:

No

District 155 - Language Codes Code 000 001 002 003 004 005 006 007 008 009 010 011 012 013 014 015 016 017 018 019 020 021 022 023 024 025 026 027 028 029 030 031 032 033 034 035 036 037 038 039 040 041 042 043 044 045 046 047 048 049 050 051 052 053 054

Language English Spanish Greek Italian Polish German Algonquin Serbian Korean Pilipino (Tagalog) Arabic Japanese French Samoan Hindi Burmese Yiddish Lithuanian Ukrainian Hungarian Czech Cantonese (Chinese) Thai Portuguese Swedish Assyrian (Syriac, Aramaic) Armenian Romanian Dutch/Flemish Hebrew Mandarin (Chinese) Farsi (Persian) Turkish Urdu Vietnamese Russian Cebuano (Visayan) Gujarati Latvian Sioux (Dakota) Norwegian Danish Albanian, Gheg (Kosovo/Macedon) Comanche Finnish Slovak Swahili Taiwanese/Formosan/Min Nan Creek Haitian-Creole Chippewa/ Ojibawa/ Ottawa Gbaya Ewe Panjabi (Punjabi) Bemba

Code 055 056 057 058 059 060 061 062 063 064 065 066 067 068 069 070 071 072 073 074 075 076 077 078 079 080 081 082 083 084 085 086 087 088 089 090 091 092 093 094 095 096 097 098 099 100 101 102 103 104 105 106 107 108 109

Language Bulgarian Apache Gaelic (Scottish) Macedonian Malay Malayalam Navajo Indonesian Kannada (Kanarese) Estonian Chichewa (Nyanja) Kashmiri Bengali Hmong Kanuri Icelandic Ga Menominee Cambodian (Khmer) Lao Shona Afrikaans (Taal) Nepali Marathi Oneida Hausa Hemba Pima Isoko Pueblo Ibo/Igbo Telugu (Telegu) Choctaw Winnebago Kikamba (Kamba) Yoruba Maltese Luo Romany (Gypsy) Tamil Hopi Slovenian Cherokee Crow Other Mandingo (Mandinka) Mende Gaelic (Irish) Akan (Fante, Asante) Tuluau Amharic Oulof (Wolof) Balinese Chamorro Tigrinya (Tigrigna)

Code 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165

Language Assamese Eskimo Bagheli Hakka (Chinese) Welsh Guyanese Bisaya (Malaysia) Chechen Pampangan Konkani Krio Kurdish Lingala Luganda Luyia (Luhya) Lunda Yombe Okinawan Oriya Orri (Oring) Ilocano Pashto (Pushto) Sikkimese Sindhi Sinhalese Sotho Kashi (Uyghur) Tibetan Maori Kache (Kaje, Jju) Mina (Geser-Goram) Mongolian Kpelle Ilonggo (Hiligaynon) Efik Sourashtra (Saurashtra) Mien (Yao) Chaochow/Teochiu (Chinese) Fukien/Hokkien (Chinese) Hainanese (Chinese) Shanghai (Chinese) Croatian Bosnian Albanian, Tosk (Albania) Tongan Uzbek Jamaican Dinlea (Turkish) Chaldean Kanjobal Palauan Hawaiian Maay or Mai Mai Krahn (Liberia, Cote 'de Ivoire) Somali American Sign Language