School Enrollment Form
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1ST. JOSEPH COMMUNITY CONSOLIDATED SCHOOL DISTRICT #169
PO BOX 409
ST. JOSEPH, IL 61873
ENROLLMENT FORM
Starting Date
Grade Level_
___
Teacher _____
___________
Legal Name
_____
Last
First
Middle
Student lives with:
Mother
Father
Both
Non-Custodial Parent
Other __________________
Address
_____
Number & Street
Apt. No.
City
Zip
Name Used (If different from legal name)
_____
Birth Date
Male / Female
Telephone Number ____________________________
Father
_____
Name
Address
Phone #
Father’s Employment and #:_________________________________________________________________________
nd
Father’s Cell #
Pager or 2
Cell #
__________
Father’s Email Address:
____
Mother
____
Name
Address
Phone #
Mother’s Employment and #:________________________________________________________________________
nd
Mother’s Cell #
Pager or 2
Cell #
__________
Mother’s Email Address:
____
rd
3
Emergency Contact Name and #:
____
Relationship to Child
th
4
Emergency Contact Name and #:
____
Relationship to Child
Sitter Name & #:
____
Schools this student has previously attended:
Name of School
Address (City & State)
Grade
____
_______________________________________________________________________________________________
____________________________________________________________________________________________
Services student has received at previous schools: ( ) Speech
( ) Social Work
( ) Counseling
( ) Remedial Reading
( ) Health Services
( ) Learning Disabilities
( ) Behavior Disorder
( ) Behavior Plan
( ) Gifted/Talented
Government agencies require periodic reports on the sex and ethnicity of students. This data is for analysis and reporting only. Please check the
appropriate category.
( ) White/Not Hispanic
( ) Black/Not Hispanic
( ) American Indian/Alaskan Native
( ) Asian/Pacific Islander ( ) Hispanic
English is primary language spoken in the home. (circle one)
Yes
No
If no what language is spoken ______________________________
Guardian of student is an active member of the military (circle one)
Yes
No
Other children in family:
Name
Birth Date
Grade/Teacher
Living at Home or School
M/F
______
Parent Signature _______________________________________ Today’s Date_________________________________
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