Sparta Community Unit District #140
2015-2016 Registration/Emergency Form
Student’s Name (First, Middle, Last)
Sex
Birth Date
Race*
Soc Security #
Grade
Office Only
Entry Date fees rec’d
Y
N
Y
N
Y N
Y
11-Hispanic/Latino 15-Native Hawaiian/Pacific Islander
Racial 13-Asian
14-Black
12American Indian/Native Alaskan
16-White
N
17- Multi-
Custodial Parent or Legal Guardian’s, with whom the student(s) reside, contact information:
1
Name:
2
Name:
home
phone:
work
phone:
work
phone:
Address:
City:
cell
phone:
cell
phone:
e-mail:
Zip code:
Yes or No: Is your child eligible to ride the bus? If yes, Bus #_________
Student(s) live with:
Both Parents
(please select one)
Mother
Father
Mother/Stepfather
Father/Stepmother
Guardian*
*Please indicate the guardian’s relationship to the student(s):
I certify that the above listed address is my permanent residence.
signature:
Additional Emergency Contact Information: (please list in priority order)
5
Name:
Relationship:
Phone:
6
Name:
Relationship:
Phone:
7
Name:
Relationship:
Phone:
Language Survey: What is the primary language spoken in the home? _________________________________________________
Yes or No: I fully understand the severity of the weapons policy and will discuss this policy and the code of conduct consequence with
my child(ren).
Is there a veteran living in your household? Yes___ No___ If yes, how are they related to student? ______________
This is to verify that all of the information provided on this form is true and accurate to the best of my
knowledge. My child(ren) is a legal resident of the Sparta Community School District #140, residing within the
boundary lines of said district, and mandated by the Illinois State Board of Education or I have provided an
“Affidavit of Enrollment and Residency” form.
Signature of Custodial Parent or Guardian
Office Use Only:
Proof(s) of Residency:
Occupancy Permit
Date
Tax Bill
Official’s Initials:
Affidavit
Teacher:
Utility
SIS #:
Lease or Mortgage