CHS Online Intent to Return Form (2022-2023)

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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/

Date: *

年

月

日

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 2022-2023 school year. We further understand that the code of conduct, use of technology, and classroom rules remain the same. *

Agreed

其他:

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