Will County School District 92

3/2015

Will County School District 92

Registration/Emergency Information Form 2015-2016

Walsh SchoolReed SchoolLudwig SchoolOak Prairie Junior High

FOR OFFICE USE

District Entry DateSchool Entry DateStudent IDGraduation YearHome Room

STUDENT BASIC INFORMATION (Please Print)

Last, First, MGender (M/F)Subdivision

Home Address (Street, City, State Zip)

Birth Date (XX/XX/XXXX)Birth Place (City, State) Home Phone (incl. AreaCode)

Medical Information (Please Print)

Doctor’s NamePhone (incl. Area Code)

Medical Alerts: ______

Allergy Alerts: ______

In case of emergency, after all attempts have been made to contact you, do you give the school permission to call a physician or take whatever action is deemed necessary? YES NO

Home Language Survey(Please Print)

The state requires the district to collect a Home Language Survey for every new student. This information is used to count the students whose families speak a language other than English at home. It also helps to identify the students that need to be assessed for English language proficiency.

Please complete each question

1)Is a language other than English spoken in your home?______Yes______No

What language?______

2)Does your child speak a language other than English?______Yes______No

What language?______

If the answer to either question is yes, the law reguires the school to assess your child’s English language proficiency.

FIRST ADULT CONTACT INFORMATION(Please Print)

NameMaiden NameRelationship to studentMarital Status

Home Address (Street, City, State Zip)Email Address

Employer/Company NameHome PhoneWork PhoneCell Phone (incl. Area Codes)

Do you live with the student?___Yes___NoDo you have legal custody of the student?___Yes___No

SECOND ADULT CONTACT INFORMATION(Please Print)

NameMaiden NameRelationship to studentMarital Status

Home Address (Street, City, State Zip)Email Address

Employer/Company NameHome PhoneWork PhoneCell Phone (incl. Area Codes)

Do you live with the student?___Yes___NoDo you have legal custody of the student?___Yes___No

EMERGENCY CONTACT INFORMATION – OTHER THAN PARENTS (Please Print)

NameRelationship to studentHome PhoneWork PhoneCell Phone (incl. Area Codes)

SignatureDate