Address: Street City State Zip Code Home Phone: Address:

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1 SANDWICH CUSD #430 REGISTRATION FORM SCHOOL YEAR SELECT AN ATTENDANCE CENTER LG Haskin Prairie View WW Woodbury HE Dummer Middle School High School 1. NAME: 5. SEX: Male Female Last Name First Name Middle Name 2. STUDENT ID NUMBER (if known): 6. GRADE LEVEL: 3. ETHNICITY: White (Non-Hispanic) (Choose one) American Indian/Alaskan Hispanic Black (Non-Hispanic) Native Pacific Islander Multi-Racial Other 4. STUDENT CONTACT INFORMATION (Where student resides): 7. DATE OF BIRTH: 8. PLACE OF BIRTH: 9. MOTHER S MAIDEN NAME: Address: Street City State Zip Code Home Phone: Address: 10. CUSTODIAL PARENT/GUARDIAN CONTACT INFORMATION: (**NOTE ** ONLY Custodial or Non-Custodial Parents/Guardians may report student absences) Father: Cell#: Address: City: Zip Code: Mother: Cell#: Address: City: Zip Code: Relationship to student: Language Spoken at Home: Mother s Employer: Father s Employer: 11. NON-CUSTODIAL PARENT INFORMATION (IF APPLICABLE): Home Address: Home Phone: Work Phone: Work Phone: Name: Cell#: Address: City: Zip Code: Name: Cell#: Address: City: Zip Code: Address: Relationship to student: Home Phone: Language Spoken at Home: Cell Phone: Employer: Work Phone: Please choose a communication preference for the non-custodial parent (send newsletters, report cards, copies of correspondence): Yes Not Necessary Court order No communication of any kind allowed. (Please provide copy of court order.) 12. SIBLINGS ENROLLED IN DISTRICT: Name School Grade Level

2 13. EMERGENCY CONTACT INFORMATION (other than person student resides with): Name: Relation to Student: Home Phone: Cell Phone: Name: Relation to Student: Home Phone: Cell Phone: ALERTNOW-SISCALL is a notification system that has been implemented by Sandwich School District #430. This automated system will contact designated households with emergency information. We will be using ALERTNOW-SISCALL to notify you of school delays or cancellations due to inclement weather. Please fill out the form below so the school will have your up-to-date contact information. This will ensure that the persons you want contacted will receive the information. We will use the home phone number and parents cell numbers. If you want to include an additional contact phone number, please list it. These numbers are not necessarily the same as your emergency numbers on the registration card which are used in the case of injury or illness. Home Phone Number: Mother s Cell Phone: Primary Family Address: Optional Phone Number: Father s Cell Phone: 14. PHOTO RELEASE: Your child s attendance center may use your child s photograph in an interest story during the course of the school year. Please select whether you WILL ALLOW or NOT ALLOW your child s image to be used in the school publications: I DO authorize the use of my child s image in area newspapers, on the school websites, school maintained social networking websites, in the school yearbook and within the school building. I do NOT authorize the use of my child s image for any publications. 15. CITY LIMIT FIELD TRIPS: I give permission for my child to go with the student s class trip within the city limits of Sandwich during the course of the school year. Yes No 16. MEDICAL DATA: The school nurse has permission to share health information on a health concerns list concerning my child with appropriate members of the educational team for use in meeting the health and educational needs of the student. This will be done only on a need to know basis, in a confidential manner. The consent will be valid for the school year and may be rescinded by the consenting party at any time. I/We give consent to share medical information as described above? Yes No Family Doctor: Family Dentist: Office Phone: Office Phone: Vision: Does student wear glasses/contacts? Yes No Hearing: Does student wear hearing aid? Yes No Regular Medication? Yes No If yes, please list medication(s): Seizures? Yes No If yes, please explain: Diabetes? Yes No If yes, please explain: Asthma? Yes No If yes, please explain: Significant Allergies? Yes No If yes, please explain Other health problems, especially those which require restricted activity or special attention: Please be sure all sections on both sides of card have been completed. Signature (line indicated below) is required on all registration cards. Thank you. Parent/Legal Guardian Signature Relationship Date Signed

3 SANDWICH CUSD #430 REGISTRATION FORM KINDERGARTEN AND/OR NEW STUDENT ADDENDUM SCHOOL YEAR *** PARENTS, you MUST meet with the counselor or secretary at the school! *** KINDERGARTEN STUDENTS ONLY We are busy making plans for kindergarten classes. Ordering needed materials, planning schedules, and talking about the daily kindergarten plan is exciting and exhausting. We have planned that all kindergarten lunches will be at 11:45 AM, so our half-day students will be going home at 11:45 AM. As you know, parents may choose all-day or half-day kindergarten. In order to continue planning for our classes, we need to know your plans. Once you have made your decision for half-day or fullday kindergarten, you will have until the end of the first quarter of the school year to make a change. You will only be able to change your child s placement between half-day and full-day one time. Please feel free to call your child s school building if you have any questions. Child s name: My child will attend all-day kindergarten. My child will attend half-day kindergarten. Did your child attend Pre-School? Yes No If YES, where: NEW STUDENTS ONLY 1. SPECIAL EDUCATION SURVEY Has your child ever received special speech services? Yes No Did your child receive special services at the prior school? Yes No Did your child receive an I.E.P. at the prior school? Yes No Attendance Center: (USE School selected on FIRST page) 2. HOME LANGUAGE SURVEY The State of Illinois requires the district to collect a Home Language Survey for every new student. This information is used to count the students whose families speak a language other than English at home. It also helps to identify the students who need to be assessed for English language proficiency. Please answer the questions below and return this survey to your child s school with the registration materials. Student s Name: Today s Date: Last Name First name Middle Grade: Birthday: Gender: Male Female This school program works to build skills necessary for success in school. Check your areas of interest: Helping with reading, math, science Classroom assistant Clerical Translation/ interpretation, specify language: Part A Is a language other than English spoken in your home? Yes Language spoken: No Does your child speak a language other than English? Yes Language spoken: No Part B What was the first language your child learned? What language do you use most often to speak to your child? Which language does your child use most often when he/she: Speak to friends: Speaks to you: Did your child attend school in another country? Yes how many years? What grades? No Number of years and months your child attended school in the United States: If the language spoken in your home is other than English, would you be interested in volunteering in the English Language Learning Program of Instruction? Yes No

4 SANDWICH COMMUNITY DISTRICT #430 SCHOOL BUS FORM YEAR THIS FORM MUST BE RETURNED FOR ALL STUDENTS BECAUSE AT SOME POINT DURING THE YEAR, ALL STUDENTS WILL BE RIDING A BUS FOR FIELD TRIPS-EXTRA CURRICULAR TRIPS- SPORT TRIPS. *ONLY ONE FORM NEEDS TO BE COMPLETED PER FAMILY * RETURN TO ATTENDING SCHOOL BY MAY 6 TH. STUDENT INFORMATION: PLEASE NOTE: WE DO NOT PICK UP FROM DAY CARE PROVIDERS 1. Last Name: First Name: School Attending: Grade: Date of Birth: 2. Last Name: First Name: School Attending: Grade: Date of Birth: 3. Last Name: First Name: School Attending: Grade: Date of Birth: If additional students, please provide information on the reverse side. FAMILY INFORMATION: Home (911) Address: Home Phone: (No P.O. Boxes) Parent/Guardian Name: Work Phone: Cell Phone: Parent/Guardian Name: Work Phone: Cell Phone: EMERGENCY DATA: If we are unable to contact parents in case of illness, injury or emergency, whom shall we call: Name: Relationship: Home Phone: Cell Phone: I understand the Bus Conduct rules and the consequences for misbehavior which could include suspension or revocation of bus privileges. I understand that all riders are subject to audio and video surveillance. Parent Signature: Date Signed:

5 SANDWICH SCHOOL DISTRICT # S. Wells Street Sandwich, Illinois (815) INTERNET CONSENT AND WAIVER FORM STUDENT NAME: First Name Middle Name Last Name Grade Parent or Guardian (choose ONLY ONE of the following): INTERNET USE CONSENT As the parent or guardian of this student, I have read the guidelines set forth by Sandwich School District #430 for use of the Internet which are located in the student handbook. I understand the purpose of the use of the Internet is educational. I understand that some materials on the Internet may be offensive and that my child should not visit such sites while using the Internet. I recognize that Sandwich School District #430 is not responsible for the information on the Internet. I further understand that should my child commit any violation of the guidelines the child s access privileges may be revoked, and school disciplinary action and/or appropriate legal action may be taken. In consideration for using the district s Internet connection and having access to public networks, we hereby release Sandwich School District #430 and its board members, employees, and agents from any claims and damages arising from use, or inability to use the Internet. I accept full responsibility for supervision if and when the child s use is not in a school setting. I give my permission for my child to use the district s access to the Internet. Parent/Guardian Signature Date INTERNET USE NON-CONSENT As the parent or guardian of this student, I have read the guidelines set forth by Sandwich School District #430 for use of the Internet. I do not give my permission for my child to use the district s access to the Internet. Parent/Guardian Signature Date Student: I understand and will abide by the Sandwich School District #430 guidelines for use of the Internet which are located in the student handbook. I further understand that if I violate these guidelines I am subject to disciplinary measures by the school authorities. I also understand that if I do not follow the guidelines set forth by the Sandwich School District #430, my use of the Internet will be terminated. Student Signature Date Grade Student Consequence for going to inappropriate site(s): Student will not be able to use any computer that has access to the Internet for the remainder of the school year. Student will be obliged to find Internet sources outside of school. Student will also be given a one hour detention. Any reoccurrence of that student using the Internet at school will result in additional disciplinary consequences. *Internet permission may be changed by parent(s)/guardian(s) requesting it at any grade level.