CHS Change Of Information Form
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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SIUE East St. Louis Campus
Student's name: *
Student's date of birth: *
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Reason for change: *
Please be sure to complete the change based on your selection(s) on the following fields.
Please check all that apply
New phone number
New address
New email
Other
New phone number(s):
Please include Primary, Cell, & Work numbers.
New address:
Please include City, State, & ZIP Code.
New email: *
Other (please specify):
Parent's signature: *
Signature date: *
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Submit
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