Elwood C.C.S.D. #203 PreSchool Registration Form

1

Student Name* This field is required.

First Name

Middle Initial

Last Name

2

Birth Date* This field is required.

3

Gender* This field is required.

Male

Female

4

Mailing Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

5

With whom does the child reside with* This field is required.

Mother

Father

Both Parents

Other

6

Are there any parent/guardian custodial concerns the school should be aware of?* This field is required.If yes, please provide any and all relevant documents.

Yes

No

7

Is either parent in the military?* This field is required.

Yes

No

8

Are you Hispanic or Latino?* This field is required.

No

Yes

9

Race:* This field is required.

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian/Other Pacific Islander

White

10

Does your child have an IEP (Individual Education Plan)* This field is required.

Yes

No

11

IEP InformationIf you answered in the affirmative to the above question, please select the type of IEP.

Learning Disability

Behavior Disorder

Speech/Language Services

12

Does your child have a 504 Plan?* This field is required.

Yes

No

13

You must present ONE (1) of the following items (Category 1):* This field is required.Registration is not complete without this document

Real Estate Tax Bill

Signed Lease (current)

Mortgage Statement (current date)

Closing Papers (within 3 months of registration)

14

Would you like to use your device to upload a document or photo?If you choose no, please bring Category 1 document to school office for copying.

Yes

No

15

Upload Residency Document from Category 1Upload a photo/document from your computer or mobile device. Mobile devices allow for camera use to upload required document

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

16

You must present TWO (2) of the following items (Category 2):* This field is required.Registration is not complete without these documents

Driver's License (with Elwood address)

Gas, Electric or Phone Bill

Vehicle Registration (current year)

SNAP, TANIF or Medicaid Card (with address)

Insurance Papers (home owner's)

17

Would you like to use your device to upload a document or photo?If you choose no, please bring Category 2 document to school office for copying.

Yes

No

18

Upload Residency Document from Category 2Upload a photo/document from your computer or mobile device. Mobile devices allow for camera use to upload required document.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

19

Please select your preference session below. Please note this is just a preference, not a guarantee* This field is required.

AM - 3 year old program - (3 days per week - tuition per month is $170.00)

PM - 3 year old program - (3 days per week - tuition per month is $170.00)

AM - 4 year old program - (5 days per week - tuition per month is $250.00)

PM - 4 year old program - (5 days per week - tuition per month is $250.00)

AM - 4 year old - 3 days per week - tuition per month is $170.00

PM - 4 year old - 3 days per week - tuition per month is $170.00

20

Payment Method:Payment is due at the time of registration

Check

Cash

21

Would you like to be included in Elwood CCSD #203 informational updates via text message?* This field is required.Emergency school closures will be sent via voice message.

Yes, I authorize school authorities to send me informational updates via text message. Standard text and date rates may apply.

No, I do not authorize school authorities to send me informational updates via text message.

22

Fire Department Procedure* This field is required.By responding with a "Yes", I approve Elwood Fire Department Rescue unit in the event of serious accident, injury or illness to transport my child to the nearest emergency medical facility. The cost of transportation remains the responsibility of the parent/guardian. Please sign below, indicating you have read and understand these statements. Elwood School District #203 does not carry student accident insurance nor does it insure for such occurrences.

Yes

No

23

If I cannot be reached in an emergency, and if in the judgment of the school authorities immediate/hospital attention is indicated, I authorize responsible school authorities to accompany my child to an available hospital.* This field is required.

Yes, I authorize school authorities to accompany my child to the hospital.

No, I do not authorize school authorities to accompany my child to the hospital.

24

Website Authorization* This field is required.By checking "Yes", I give permission for my student to be interviewed, photographed, or videotaped by the news media or an agent of the school district for the purpose of publicizing a school event, activity or program at Elwood School District #203. This media may present in yearbooks, features or documentaries, district publications and communication materials, or on the district/school website. All images and rights shall belong to Elwood School District #203.

Yes

No

25

Parent/Guardian SignatureUse mouse or touchscreen

Clear

26

Parent / Guardian Contact #1* This field is required.

First Name

Middle Initial

Last Name

28

Mailing Address* This field is required.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

29

E-mail Address* This field is required.

example@example.com

30

Land Line NumberPlease place dash between number (i.e. XXX-XXX)

Area Code

Phone Number

31

Cell Phone Number* This field is required.Please place dash between number (i.e. XXX-XXX)

Area Code

Phone Number

32

Work Phone NumberPlease place dash between number (i.e. XXX-XXX)

Area Code

Phone Number

33

Parent / Guardian Contact #2

First Name

Middle Initial

Last Name

35

E-mail Address

36

Mailing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

37

Land Line NumberPlease place dash between number (i.e. XXX-XXX)

Area Code

Phone Number

38

Cell Phone NumberPlease place dash between number (i.e. XXX-XXX)

Area Code

Phone Number

39

Work Phone NumberPlease place dash between number (i.e. XXX-XXX)

Area Code

Phone Number

40

Emergency Contact #1

First Name

Middle Initial

Last Name

41

Relationship to Child

42

Land Line NumberPlease place dash between number (i.e. XXX-XXX)

Area Code

Phone Number

43

Cell Phone Number

Area Code

Phone Number

44

Emergency Contact #2

First Name

Middle Initial

Last Name

45

Relationship to Child

46

Land Line Number

Area Code

Phone Number

47

Cell Phone Number

Area Code

Phone Number

48

Parent/Guardian SignatureUse mouse or touchscreen

Clear