(As is appears on the student's birth certificate or legal document)
Your answer
Gender: *
Date of Birth: *
MM
/
DD
/
YYYY
Birthplace: *
City, State OR Country (if outside of the U.S.)
Your answer
Language First Acquired: *
Your answer
Language most often spoken at home: *
Your answer
Does the child need ESL (English as a Second Language)? *
Ethnicity: *
Required
Home Address: *
Your answer
Home Phone Number: *
Your answer
FAMILY DATA
Student lives with: *
Required
Father/Guardian Name: *
Please type "none" if not applicable.
Your answer
Father's/Guardian's Cell Phone Number: *
Please type "none" if not applicable.
Your answer
Father's/Guardian's Work Phone Number: *
Please type "none" if not applicable.
Your answer
Father's/Guardian's Email Address: *
Please type "none" if not applicable.
Your answer
Father's/Guardian's Home Address (if different than the student's):
Your answer
Is the Father/Guardian allowed to pick up the student? *
Is the Father/Guardian an Emergency/Medical Contact? *
Mother/Guardian Name: *
Please type "none" if not applicable.
Your answer
Mother's/Guardian's Cell Phone Number: *
Please type "none" if not applicable.
Your answer
Mother's/Guardian's Work Phone Number: *
Please type "none" if not applicable.
Your answer
Mother's/Guardian's Email Address: *
Please type "none" if not applicable.
Your answer
Is the Mother/Guardian allowed to pick up the student? *
Mother's/Guardian's Home Address (if different than the student's):
Your answer
Is the Mother/Guardian an Emergency/Medical Contact? *
SPECIAL CIRCUMSTANCES
Please describe any circumstances regarding custody/residency that exist. Provide appropriate documentation. *
Please type "none" if not applicable.
Your answer
SIBLINGS
Please provide information for EACH sibling that attend an Elmwood Park school. Please type "none" if not applicable.
Provide sibling's full name, grade, and school attending in Elmwood Park: *
Your answer
EMERGENCY/MEDICAL CONTACTS
* Provide information OTHER than Parents/Guardians. ** Any contact listed will be allowed to pick up child, unless otherwise stated by parent. Student will not be released to anyone that is not listed as an emergency contact.
Emergency Contact #1 Name: *
Please type "none" if not applicable.
Your answer
Emergency Contact #1 Phone Number: *
Please type "none" if not applicable.
Your answer
Emergency Contact #2 Name: *
Please type "none" if not applicable.
Your answer
Emergency Contact #2 Phone Number: *
Please type "none" if not applicable.
Your answer
EDUCATIONAL INFORMATION
Is it first time entering school in United States? *
Date that student entered United States (if from another country):
MM
/
DD
/
YYYY
If your child was not born in the US, what grade did he or she enter in a US school?
Your answer
Is this the student's first time entering school in the Elmwood Park School District? *
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