CHS Online Intent to Return Form (2022-2023)
SIUE East St. Louis Charter High School
601 James R. Thompson Boulevard
East St. Louis, IL 62201-1118
Phone: 618.482.8370 | Fax: 618.482.8372

Dr. Veronica (Gina) Jeffries - Director
Pamela Saffore - Interim Assistant Director

Website: www.siue.edu/education/esl-charter-school/
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Date: *
MM
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DD
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YYYY
Student's Name: *
Address: *
City, State, & ZIP Code: *
Primary phone number: *
Other phone:
Work phone & ext.: *
Name of relative or contact in case of emergency? *
Please list the relation and contact phone number. Example: Mrs. Janice Johnson | Grandmother | 618.999.9999
Please list any health concerns: *
List any prescription medications student is currently taking: *
Name of Insurance Company/Policy or Case Number/ & Phone:
As Parent(s)/Guardian(s), we wish to remain in the Southern Illinois University Edwardsville East St. Louis Charter High School for the 2021-2022 school year. We further understand that the code of conduct, use of technology, and classroom rules remain the same. *
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