Anna District #37 Registration Form

1
Student Name
First Name
Middle Name
Last Name
2
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
Birthday
Date
Month
Day
Year
4
Gender
Male
Female
5
Grade Level
Kindergarten
First
Second
Third
Fourth
Fifth
Sixth
Seventh
Eighth
6
Is this student a foster child?
Yes
No
7
Ethnicity/Race
Asian
Black/African American
White
American Indian
Hispanic/Latino
2 or more Races
8
Special health conditions of your child, please list:
9
Has this student attended an Illinois School in the past?
Yes
No
10
Previous School Address (City,State)
11
Custodial Guardian #1
Yes
No
12
Guardian #1 Name
First Name
Last Name
13
Address (if different than students)
14
Employer & Phone Number
15
Email Address
16
Guardian #1- Please list two phone numbers for contact.
17
Custodial Guardian #2
Yes
No
18
Guardian #2 Name
First Name
Last Name
19
Address (if different than students)
20
Employer and Phone Number
21
Email Address
22
Guardian #2 - Please list two phone numbers for contact.
23
May the school contact you through email?
Guardian #1, Yes
Guardian #1, No
Guardian #2, Yes
Guardian #2, No
24
Emergency Contact #1    First Name     Last Name
Phone #1    Area Code     Phone Number
Phone #2    Area Code     Phone Number
Emergency Contact #2    First Name     Last Name
Phone #1    Area Code     Phone Number
Phone #2    Area Code     Phone Number
25
List all siblings living in the household and their grade level.
26
My Child has permission to participate in field trips and PBIS incentive trips
Yes
No
27
My child has permission to have their picture taken or video taped for educational purposes (yearbook pictures, class pictures, news articles, etc.)
Yes
No
28
My Child has permission to use the Internet while supervised in a classroom.
Yes
No
29
One or more of the custodial parents or guardians are in the armed forces, is deployed to active duty or expects to be deployed to active duty sometime during the school year
Yes
No
30
Does your child have access to the internet at home?
Yes
No
31
SignatureBy signing this document, you agree that all information is correct.
Clear
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