Registration Form Stark County CUSD #100
New Student Registration Information.
 Proof of residency - Detailed information can be found: https://stark100.com/wp-content/uploads/2019/07/Proof-of-Residency-Information.pdf

Health Requirements:
Dental Exam Form – Due for 6th & 9th grade students
School Physical – Due for 6th & 9th grade students, and students new to Illinois Public Education
Eye Exam Form – Only students new to Illinois Public Education
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Email *
Student Full Name (first, middle, last) *
Student Home Address, City, State, Zip *
Mailing Address (if different from home address)
Student Birthday *
MM
/
DD
/
YYYY
Grade Entering: *
Previous School - Name, Address, Phone number *
Gender *
Place of Birth: (City & State) *
Race (Check all that apply) *
Student lives with: *
Please list Siblings names and grade: *
Mother/ Primary Guardian Name *
Address *
Phone Number - Mother/Primary Guardian *
F1/G1 Email Address *
F1/G1 Employer & Work Phone *
Father/Guardian Name *
Address - Father/Guardian *
Phone Number - Father/Guardian *
F1/G2 Email Address
F1/G2 Employer & Work Phone *
Would you like report cards sent to non-custodial parent? *
Verify mailing address for non-custodial parent
Does your student receive any special services? *
Non-Parent Emergency Contacts
Please complete the following information for someone other than parents or those listed above
#1 Emergency Contact (Name, relationship, phone#) *
#2 Emergency Contact (Name, relationship, phone#)
#3 Emergency Contact (Name, relationship, phone#)
Physician & phone number, preferred Hospital
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