Elementary Student Registration Form - Champaign Community School District 4 printable pdf download

CHAMPAIGN COMMUNITY SCHOOL DISTRICT #4 | ELEMENTARY STUDENT REGISTRATION FORM

STUDENT INFORMATION

ACADEMIC YEAR 20____ - 20____

Indicate R if a student is NEW q to the Champaign Unit #4 Schools TRANSFERRING q within Unit #4 RETURNING q to Unit #4

_____________________________________________________________ Birth Date: _________________________

Student Name:

First Name

Last Name

Month/Day/Year

_____________________________________________ ______ _______________________________ ________________

Address:

Street

Apt

City

Zip

:__________

: ____ – ____________

Phone

Sex: q Girl q Boy

Grade

SPECIAL EDUCATION SERVICES RECEIVED:

q Yes

q No

Services Received: _______________________

ETHNIC R: q Hispanic

q Non Hispanic

CHILDREN OF U.S. MILITARY

PERSONNEL

RACE R: q (01) White

q (02) Black or African-

American q (04) Asian

q (05) Native

Is parent/guardian actively deployed or

Attended (Please check one):

anticipating deployment during this school

American/Alaskan

q Head Start

q Day Care

year?

q (06) Native Hawaiian/Pacific Islander

q CECC

q None

q Yes

q No

q (0) Multi-Racial

q Private Pre School

FAMILY INFORMATION

q Parents

q Mother Only

q Father Only

q Guardian

q Grandparents

q Foster Parents

Lives with R:

___________________________________________________________

Mother/Female Guardian:

E-mail: ____________________________

Last Name

First Name

__________________________________

__________

______

_____________

Employer:

Daytime/Work Phone:

ext.:

Cellular/Pager:

______________________________________________________________

________________________

Father/Male Guardian:

E-mail:

Last Name

First Name

__________________________________

__________

______

_____________

Employer:

Daytime/Work Phone:

ext.:

Cellular/Pager:

: _________________

HOME LANGUAGE: ________________________

COUNTRY OF BIRTH: ________________________

DATE FIRST ENROLLED IN U.S. SCHOOLS

List Other School-Age Children:

School

Grade

School

Grade

_________________________

________________________

Name:

_________________________

________________________

Name:

Are there any pre-school age children in your home? ______ Please indicate name(s) and age(s): ______________________________________

EMERGENCY INFORMATION (Other than Parent/Guardian)

____________________________________________ _______________________ ______________________

Emergency Contact:

Name

Relationship

Daytime Phone

q Yes

q No

____________________________

Daily Medication(s):

Will the medication be administered during the school day?

____________________

____________________________

Health Restrictions:

Family Physician:________________________ Telephone:

IMPORTANT: In an extreme medical emergency your child will be taken by ambulance to the hospital that you identify below.

Please select a hospital and sign your name.

q Carle Trauma Center

q Provena/Covenant

_____________________________________________

Parent/Guardian Signature:

In case of a minor incident, efforts will be made to contact you for direction. All medical fees are the parent(s)/guardian(s) responsibility.

ELEMENTARY SCHOOL PREFERENCE INFORMATION

Please rank all 12 schools according to preference; making at least 5 choices. Use the numbers 1, 2, 3, 4, 5, etc. to indicate choices. (Transportation is

provided to those living more than 1½ miles from the school chosen.) Please be advised that some academic programs may only be offered at

particular, designated schools.

Magnet School Options:

Barkstall

Dr. Howard

South Side

Washington

Bottenfield

Kenwood

Westview

Garden Hills

Carrie Busey

Robeson

International Prep Academy

Stratton

___________________

Parent/Guardian Signature: _____________________________________________________________

Date:

I certify that the information provided on this form is true.

•Parents that participate in the Magnet registration grades 1-5 and receive an assignment are not eligible to participate in the transfer period in the same school year.

FOR OFFICE USE ONLY

Student ID: _______________ Assigned: _______ Special Program: ______ Special Ed.: _________ Proximity School: __________________

Entered eSchool: ______________ Entered Controlled Choice:_________________ Entered Data:______________

Rev. 12/4/2013

FIC STAFF