Parent/Guardian Last Name
First Name
Middle Initial
Relationship to Child (i.e. Father, Step-mother etc.)
Spouse or Second Adult Last Name
Relationship to Child (i.e. Father, Step-mother, etc.)
Physical Home Address
P. O. Box Number
City/Village
State
Zip Code
Home Telephone Number
Cell Phone Number
Email Address
County
Township, City or Village of
Child's Data
1. List any child between the ages of new born to 20 years of age residing at the address listed above.
2. If any child has a diagnosed disability, and needs special education services from the school district, mark the Special Needs box.
Last Name
M.I.
Gender
Birthday (MM/DD/YYYY)
Ethnic code
School attending
Grade Attending
Special Needs: If your child has a diagnosed disability, and needs special education services from the school district, choose the "Yes" button.