Office Use Only
Entered:_______ Dropped:_______ Records Rqstd:__________ Records Rcvd:___________ Teacher:________________________Grade:_______
STUDENT INFORMATION EDWARDSVILLE CUSD#7 SCHOOL YEAR: BLDG:
STUDENT NAME: (First, Middle, Last) STUDENT'S BIRTHDATE: ______________
GENDER: _________
______________________________________________________
STUDENT'S BIRTHPLACE: _________________________________
STUDENT NICKNAME: _____________________
MOTHER'S MAIDEN NAME: ________________________________
PRIMARY PHONE: ___________________ LISTED (Y/N): _____ SPECIAL CUSTODY INFORMATION:
STUDENT ADDRESS:
_______________________________________________________
SCHOOL STUDENT LAST ATTENDED:
House# Street Name Apt# PO Box
NAME/PHONE:___________________________________________
STREET/CITY/STATE/ZIP: _________________________________
City State Zip
DATES ENROLLED (MM/YY): ____________ TO____________
PLEASE CHECK IF YOU ARE CURRENTLY HOMELESS PLEASE CHECK IF STUDENT WAS IN GIFTED PROGRAM
Special Education Information: __________
(I-IEP; R-no special education services; S-Speech only; 5-504)
PRIMARY PARENT(S)/GUARDIAN(S) NAME(S) WITH WHOM STUDENT LIVES: ___________________________________________
RELATIONSHIP TO STUDENT: ____________________ (1-Both parents; 2-Mother Guardian; 3-Father Guardian; 4- Mother/Stepfather; 5-Father/Stepmother; 6-
Both Guardians; 7-Foster Parents; 8-Independent; 9-Other)
(Enter the number describing the relationship of the primary guardian to the student)
FATHER/GUARDIAN MILITARY (Y/N): ___ DEPLOYED (Y/N): ___
FATHER/GUARDIAN DATE OF BIRTH: ___________
WORK PHONE: ________________________
CELL PHONE: _________________________
EMAIL: ___________________________________________
MOTHER/GUARDIAN MILITARY (Y/N): ___ DEPLOYED (Y/N): ___
MOTHER/GUARDIAN DATE OF BIRTH: ___________
WORK PHONE: ________________________
CELL PHONE: ________________________
EMAIL: ______________________________________
SECONDARY PARENT(S)/GUARDIAN(S) (not listed above) LEGALLY ENTITLED TO BE CONTACTED AND RECEIVE REPORT CARDS,
PROGRESS REPORTS, AND MAILINGS:
NAME: _____________________________________ DATE OF BIRTH: ___________ RELATIONSHIP: __________________
CITY: ________________________ STATE: _________________
ADDRESS: ___________________ ZIP: ____________
HOME PHONE: ________________ WORK PHONE: _________________
CELL PHONE: _________________
EMAIL: ______________________________ SECONDARY GUARDIAN ACTIVE DUTY MILITARY (Y/N): _____ DEPLOYED (Y/N): ____
STUDENT'S PHYSICIAN & PHONE: __________________________ / ____________________________
THREE RELATIVES OR FRIENDS AUTHORIZED TO BE CALLED TO PICK UP CHILD IN CASE OF EMERGENCY. (OTHER THAN THE PRIMARY AND
SECONDARY PARENT(S)/GUARDIAN(S) LISTED ABOVE):
Relationship
Name Address City Phone
1.________________________ ________________________ _____________________________ ______________________ _______________
2.________________________ ________________________ _____________________________ ______________________ _______________
3.________________________ ________________________ _____________________________ ______________________ _______________
All non-confidential communications will be sent via email. If you do not wish to receive these communications via
email, please fill out the appropriate form "non-confidential mailing request."
PRIMARY PARENT/GUARDIAN EMAIL COMMUNICATIONS (Y/N): ____
SECONDARY PARENT/ GUARDIAN EMAIL COMMUNICATIONS (Y/N): _____
MEDICAL CARE AUTHORIZATION: HANDBOOK NOTIFICATION:
In case my child needs medical care and I cannot be reached, I
authorize ambulance transport to the nearest hospital. I will
assume all responsibility and expenses.
I agree to access the District 7 Handbook, which is available at
www.ecusd7.org/parents, and I am responsible for reviewing the
contents with my child.
SIGNATURE OF LEGAL GUARDIAN: SIGNATURE OF LEGAL GUARDIAN:
______________________________ ______________________________
