Sparta Community Unit District #140
2013-2014 Registration/Emergency Form
Student’s Name (First, Middle, Last)
Sex
Birth Date
11-Hispanic/Latino 15-Native Hawaiian/Pacific Islander
Racial 13-Asian
Race*
14-Black
Soc Security #
Office Only
Entry Date fees rec’d
Grade
12American Indian/Native Alaskan
16-White
Y
N
Y
N
Y
N
Y
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).
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
Utility
Official’s Initials:
Teacher:
SIS #:
If you answered yes to “Known Allergies”, “Known Health Problems” or “Medications” please specify below:
Lease or Mortgage
Sparta Community Unit District #140
2013-2014 Registration/Emergency Form
Student’s Name (First, Middle, Last)
Language Survey: What is the primary language spoken in the home? _________________________________________________
YES
NO
Please acknowledge the following by initialing in the yes or no box and sign below:
My child has permission to engage in all physical education activities. If no list reasons or limitations:
During the school year certain information may be released in various publications (yearbook, athletic
programs, news articles, news letters, academic awards, etc,) about student activities. I hereby give my
permission for Sparta Community School District #140 to release pertinent information about my
child(ren).
I hereby give my permission for my child(ren) to have their picture published on the school’s website
or school newsletter.
I have received a copy of the Authorization for Internet Access and will discuss it with my child(ren). I
hereby give my child(ren) permission to use the internet based on the school policy.
I fully understand the severity of the weapons policy and will discuss this policy and the code of
conduct consequences with my child(ren).
My child(ren) may attend all field trips throughout the school year. I understand the classroom teacher
will provide specific information prior to any field trip.
I hereby request the free loan of state-supplied textbooks in accordance with Section 17-18 of the
School Code. I understand that this request will remain valid so long as the above named student(s)
remain enrolled in Sparta Community School District #140 and that I may at anytime withdraw this
request.
I wish to register pursuant to the State of Illinois Structural Pest Control Act, 255 ILCS 235,
administered by the Illinois Department of Public Health. I understand I will be notified by the school
via “school reach” at least 48 hours prior to any spraying of pesticides in my child(ren)’s school
building. I understand I will not be notified of spraying that may occur during times that I or my
child(ren) may not be in the building during or at least 48 hours after such spraying. I understand that I
must keep a current phone number registered with “school reach” in order for notification to occur.
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.
X
Signature of Custodial Parent or Guardian
Date