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LeRoy Elementary School Pre-Registration Form
School Year 2022-2023
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* Indicates required question
Email
*
Your email
Student Name (Last, First, Middle):
*
Your answer
Student Birthdate:
*
MM
/
DD
/
YYYY
Student Grade:
*
Choose
PreK
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
Student Address:
*
Your answer
Parent/Guardian 1 Name:
*
Your answer
Parent/Guardian 1 Phone:
*
Your answer
Parent/Guardian 1 Email:
*
Your answer
Parent/Guardian 2 Name:
*
Your answer
Parent/Guardian 2 Address:
*
Your answer
Parent/Guardian 2 Phone:
*
Your answer
Parent/Guardian 2 Email:
*
Your answer
Has your child attended LeRoy Schools in the past?
*
Yes
No
Does your child receive special services?
*
IEP
504 Plan
Reading Interventions
Math Interventions
Speech Services
N/A
Birth County, City, State:
*
Your answer
Ethnicity:
*
Choose
White
Black
Hispanic
Asian/Pacific Islander
Native American
Health Concerns:
*
Your answer
Hospital of Choice:
*
Carle Bromenn
OSF
Daycare Provider:
*
Your answer
PARENT SIGNATURE:
*
By checking this box, you attest all information is true and accurate.
Required
PARENT SIGNATURE: First and last name.
*
Your answer
Submit
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