Chicago Public Schools School Enrollment Form School Name
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1Rev. 01/2014
Chicago Public Schools
School Enrollment Form
School Name__________________________________________________________________________
Student Information
School Use Only:
___________________
Prevent duplicate student records. Search in SIM for an existing Student ID before
Student ID#
Student’s siblings’ names if
creating a new one.
currently enrolled in CPS:
___________________________
___________________________
______________________ __________________ ___________________
Last Name
First Name
Middle Name
Generation (Jr., etc)
___________________________
______________ _______________________________ _________________________________________
___________________________
Gender
Birth date
Registration Grade Level
(mm/dd/yyyy)
(when first entering CPS)
Personal and Immigrant
Y / N
_______________________________________________________
Information
Birth Certificate on File
Birth Verification Type
__________________________ ________________________________
____________________________
Note to Parent/Guardian:
* Birth Country
Birth State
Birth City
Your student may be eligible for
additional resources and services
* Complete if student was not born in the United States (US) or one of its Territories:
if identified as born outside the
Date of first enrollment in any US School: ____________________________
United States (US) and/or has
refugee status. Please complete
Full Years completed school in US: ______________________________
this information.
Date first entered US: _________________________________________
Student has refugee status:
Y / N
Country of refugee:_____________________________________
School Use Only: Note that “Date of first enrollment in any US School” becomes a required field in SIM if “Birth
Country” is not the US or one of its Territories.
Student Address/Phone
__________________________________ ______ _________________
_________________
___________
Physical (Home) Address
Street Number and Name
Apt.
City
State
Zip Code
__________________________________ ______ _________________
_________________
___________
Mailing Address
Street Number and Name
Apt.
City
State
Zip Code
(if different than Home)
Home Phone Number______________________________
Demographic,
Federal Ethnic and Race Categories:
(Enter information into SIM from the Race and Ethnicity Survey form)
Home Language,
Home Language Survey:
(Enter information into SIM from the Home Language Survey form)
Parent/Guardian Contacts,
Parent/Guardian Contacts:
(Enter information into SIM from the Request for Emergency and Health Information form)
Emergency/Health Information
Emergency/Health Information:
(Enter information into SIM from the Request for Emergency and Health Information form)
Enrollment
_______________________________________________________________ __________________________________
*School Transferring From
City and State
((if not a Chicago Public, Charter or Contract School)
Enrollment Status Codes:
01 – No Former School
*Is the student in good standing?
Y / N
02 – Chicago Public School
(Instructions to school: for out-of-state public school or any private school students, a certification of “good standing” should be received
(to incl. Charter/Contract)
from the Parent/Guardian. Refer to CPS Policy 10-0623-PO1 for more information.)
03 – Chicago Private School
04 – IL Public Schl, not Chicago
Last Chicago Public, Charter, or Contract School Attended _____________________________________________
05 – IL Private Schl, not Chicago
06 – US Public Schl, not Illinois
Is the student receiving any type of Special Education services?
Y / N
07 – US Private Schl, not Illinois
(Instructions to school: if yes, please notify the Case Manager.)
08 – Not in USA
Student Enrolled by ____________________________________________________________________________
(Print Name and Relationship)
_________________________________________________________
________________________________
Signature of Parent/Guardian
Date of Enrollment
School Use Only:
Enrollment Status Code
______ Grade Level_______ Homeroom/Division #____________
(insert a # from the left)
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