Yearly Student Information Form
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2G
S
D
H
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RANTSBURG
CHOOL
ISTRICT
IGH
CHOOL
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2016-2017 Yearly Student Information
Office
Student Information
Student’s Legal Full Name
Last
First
Middle
______________________ _______________ ____________________________________
Place of birth
City
State
County
Physical Street Address
Mailing Address
(if different, such as a PO Box)
Home Phone
Land
Cell
Student Cell Phone # (optional) ______________________________
Gender
M
F
DOB
Age
Grade Level
Ethnicity (Please answer BOTH Questions 1 and 2)
1. Is this student Hispanic or Latino? (Choose one)
No, not Hispanic or Latino
Yes, Hispanic or Latino
2. Is this student: (Choose one or more)
Asian
Black or African American
Native Hawaiian or other Pacific Islander
American Indian or Alaskan Native
White
Primary Language
Secondary Language (if applies)
Resident Township
Village of Grantsburg
Anderson
Daniels
Grantsburg
Lincoln
Trade Lake
West Marshland
Wood River
Sterling
Send Student information to this address
Primary Parent(s)/Guardian(s) student resides with:
Name (Last, First)
Relationship to Student_____________________
Mailing Address
(if different from above)
Employer Name
Department
Shift (if applies) 1 2 3
Daytime Phone_____________________
Alternate Phone _____________________
Cell Home Work
Cell Home Work
Name (Last, First)
Relationship to Student_____________________
Employer Name
Department
Shift (if applies) 1 2 3
Daytime Phone_____________________
Alternate Phone _____________________
Cell Home Work
Cell Home Work
_______________________________________________________________
Family Email
Additional Parent(s)/Guardian(s) Information (such as non-custodial, co-residency, other.)
Does co-residency apply
Yes
No
(Example, resides every other week. If so , please give mileage from home to school __ miles.)
Name (Last, First)
Relationship to Student _____________________
Mailing Address _______________________________________________________________________________________________
Send student information to this address
Employer Name
Department
Shift (if applies) 1 2 3
Daytime Phone_____________________
Alternate Phone _____________________
Cell Home Work
Cell Home Work
Email _________________________________________
Name (Last, First)
Relationship to Student _____________________
Mailing Address
_______________________________________________________________________________________________________
Send student information to this address
Employer Name
Department
Shift (if applies) 1 2 3
Daytime Phone_____________________
Alternate Phone _____________________
Cell Home Work
Cell Home Work
Email _________________________________________
Please indicate which of the following items you would like the non-custodial parent to receive.
Report Cards Only
All school related information
I authorize the above non-custodial parent permission to allow our student to leave school.
I authorize the above non-custodial parent to give permission in the case of an emergency.
The High School will send student information to only 2 addresses. Please check which addresses to send to.
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