Kindergarten Registration
Frequently Asked Questions
www.ccsd59.org
v Community Consolidated School District 59 offers the following kindergarten programs:
Ø Half-day programs at all elementary schools excluding Ridge Family Center for Learning and John Jay
Elementary School.
Ø Full-day programs for District Choice Programs (see below).
Ø Full-day program for students who live within the John Jay Elementary School boundary area.
v At what age is my child eligible to attend kindergarten?
Ø In accordance with Illinois School Code guidelines, your child must be 5 years old on or before
September 1st to be eligible for kindergarten.
Ø You will need to provide an original, official government issued (not a hospital issued) original birth
certificate or passport as required by Illinois law (325 ILCS 50/5, Missing Children’s Record Act).
v Can my child go to any school in District 59?
Ø All residents in District 59 are assigned to a school based on established boundaries.
Ø Some programs, such as the English Language Learner Program or Educational Life Skills Program, are
only available at specific sites. Parents should still register their child at their assigned school or the
Administration Center.
Ø District 59 offers two Choice Programs. One is the balanced calendar program at The Ridge Family Center
for Learning. The other is the dual language program at Salt Creek Elementary School and operates on the
traditional school calendar. Parents must register for these programs at Ridge and Salt Creek. Entrance to
these programs is by lottery. Each program’s kindergarten runs on a full-day schedule. More information
about these programs can be found on the District 59 website or by contacting the school directly.
v When and where can I register my child?
Ø Registration for the 2014-15 school year begins Wednesday, February 19, 2014 from 4:00 PM to 7:00 PM at
your assigned school. This evening event is the best time to register as it provides adequate opportunity for
your child to become familiar with his/her new school.
Ø If you are unable to register on that evening, you may also register at your school beginning February 26th
between the hours of 9:30–11 and 1:00-3:00 Monday through Friday.
Ø During the summer, registrations will be accepted during regular business hours at the Administration
Center (2123 Arlington Heights Road, Arlington Heights): Monday – Thursday.
v How do I register for one of the District’s Choice Programs?
Ø You may register at Ridge Family Center for Learning Program for the balanced calendar program, or at Salt
Creek School for the dual language program. You may only register for one Choice Program.
Ø If your child does not receive a place in a Choice Program, your registration materials will be transferred to
your home school. This will not impact your class placement at your home school.
Ø The last day to register for these Choice Programs is March 20, 2014.
v What about fees?
Ø You may pay your Student Fee by cash or check at the time of registration. Checks should be made payable
to Community Consolidated School District 59.
Ø Your school will provide you a School Fee Payment Form with fee information and amounts.
BS2 Jan 2014
v
When I come in to register my student, what do I need to bring to prove I am a resident of District 59?
Category A (1 document required)
ü
Most recent real estate tax bill
ü
Mortgage papers
Signed and dated lease or letter from
manager or proof of last month’s
payment
ü
v
Category B (2 documents required)
ü
ü
Driver’s license
ü
Vehicle registration
ü
Voter registration
ü
Most recent cable or credit card
bill
ü
Current public aid card
ü
√
ü
Current homeowner’s/renter’s
insurance policy and premium
payment receipt
Most recent gas, electric and/or
water bill
Mail received at District
residence
Receipt for moving company
services showing current
address
Can I request morning (AM) or afternoon (PM) kindergarten placement?
Ø A letter from you stating your reasons for a particular placement along with evidence of enrollment in a day
care program will be taken into consideration for placement. While every effort will be made to honor
requests, many variables, such as class size, boy to girl ratio, special needs, transportation, etc., affect the
school’s decision regarding class placement. Therefore, no guarantees can be made as to placement.
Ø Final class placements are determined by the building principal.
v
What if I need day care before and/or after school?
Ø District 59 offers no day care provisions. The local park districts offer before and after school programs at
many of our school buildings. In addition, many local area day care centers provide transportation to and
from school.
v What happens if a language other than English is spoken in the home?
Ø In accordance with Illinois School Code guidelines, if a language other than English is spoken in the home,
your child will be tested for English language services. A certified teacher will administer the test and the
results will be discussed with you before any placement decision is made.
v
Can my child ride a school bus?
Ø Bus transportation will be provided if you live more than one mile from school, or if the route your child
would walk is considered to be hazardous as defined by the Illinois Department of Transportation.
Ø If your child qualifies for transportation, he/she will be expected to ride the bus on their first day of school.
v
Will my child need a physical?
Ø Yes, all kindergarten students are required by Illinois School Code to have a current (within the last 12
months) Illinois physical, as well as up-to-date immunizations before starting school.
Ø Dental examinations are required by May 15th.
Ø Vision examinations are required by October 15th.
Ø All examination forms are available in all school office and on the District’s web site.
v What happens on the first day of school?
Ø Your school will notify you of what to expect on your child’s first day of school.
v Whom do I call with questions?
Ø The best place to call is your school.
Ø If your school is not in session, please contact the Administration Building at 847.593.4300.
Ø You may also find additional information at the District 59 website: www.ccsd59.org
BS2 Jan 2014
Community Consolidated School District 59
Elk Grove Township Schools Board of Education and Administrative Offices
2123 S. Arlington Heights Road, Arlington Heights, IL 60005
847/593-4300 Fax: 847/593-4410 www.ccsd59.org
IMPORTANT INFORMATION ABOUT REGISTERING YOUR STUDENT
The enrollment of your student is not final until all required paperwork has been
completed. You will be contacted by your assigned school if your paperwork or
information is incomplete. Therefore, it is important your contact information is accurate
and is kept current.
Remember: Only students who are residents of the District may attend a District 59
school without a tuition charge, except as otherwise provided by law. A student’s
residence is the same as the person who has legal custody of the student.
Please be advised, Board of Education Policy authorizes verification and investigation of
residency, which includes the services of a private investigation service.
We encourage you to become familiar with District 59 and our schools by visiting our
website at www.ccsd59.org or contacting your school.
Brentwood School (847) 593-4401
260 Dulles Rd, Des Plaines
Admiral Byrd School (847) 593-4388
265 Wellington Ave, Elk Grove Village
Clearmont School (847) 593-4372
280 Clearmont Dr, Elk Grove Village
Devonshire School (847) 593-4398
1401 S. Pennsylvania Avenue, Des Plaines
Forest View School (847) 593-4359
1901 Estates Dr, Mt. Prospect
Frost School (847) 593-4378
1308 Cypress, Mt. Prospect
John Jay School (847) 593-4385
1835 Pheasant Trail, Mt. Prospect
Juliette Low School (847) 593-4383
1530 Highland Ave, Arlington Hts
Rupley School (847) 593-4353
305 East Oakton, Elk Grove Village
Salt Creek School (847) 593-4375
65 Kennedy Blvd, Elk Grove Village
Ridge Family Center (847) 593-4070
650 Ridge Ave, Elk Grove Village
Friendship Jr. High (847) 593-4350
550 Elizabeth Ln, Des Plaines
Grove Jr. High (847) 593-4367
777 Elk Grove Blvd, Elk Grove Village
Holmes Jr. High (847) 593-4390
1900 Lonnquist Blvd, Mt. Prospect
BS-5
Community Consolidated School District 59
A Great Place to Learn
To: Parents/Guardians:
Re: Request for Kindergarten AM/PM Placement
Every effort will be made to notify families by June 2, 2014 about morning and afternoon
kindergarten assignments for the 2014/2015 school term. While this advance notification
should assist families in making daycare arrangements for the daytime hours while
children are not in attendance at school, please be aware that final placements in AM or
PM kindergarten programs will be completed as we near the start of the school year.
Day care centers have been notified that the June 2 placement notification is preliminary
and have been asked to remain flexible in their scheduling.
It is our intent to balance morning and afternoon class assignments to avoid
overcrowding of kindergarten classes. Therefore, the final decision on placement of a
child in a morning or afternoon kindergarten class rests with a building principal. A
placement request needs to be submitted to the school where your child will attend by
May 2. Even with this early notification it may not be possible to accommodate all
kindergarten placement requests.
You will need to include with your placement request a notice from a daycare provider
indicating assignment of your child to either a morning or afternoon daycare class (or
other explanation as to the basis for your request). Placement requests will not be
considered without verification from a daycare provider (by May 2, 2014) or other
explanation as to the reason for a request. Once again, even with this verification it may
not be possible to honor all placement requests received by a school.
Please contact your childʼs building principal if you have a question about this
notification.
Thank you,
Dr. Art Fessler
Superintendent of Schools
Cc: Daycare Providers
Kindergarten through Grade 5
Instructional Materials Fee Payment Form
2014/15 School Year
PLEASE READ THE IMPORTANT FOLLOWING INFORMATION:
Fees are due prior to the first day of attendance. If you have a SNAP or TANF number or will be applying for a fee waiver, do not pay Required Fees at
this time. Only Required Fees will be waived for families who have qualified for a Waiver of Instructional Materials Fees. Please reference Board
Policy 4:140 and Administrative Regulations 4:140 R-1 and R-2 for specific information. Optional Instructional Materials Fees cannot be waived.
Consequences are applicable for non-payment of fees. Refunds are issued on a semester basis if student is enrolled for less than 10 days.
Student Information
Student Name
Student I.D. Number
School
Grade
Required Instructional Materials Fees by Grade Level
Half-Day Kindergarten
$35.00
Full-Day Kindergarten
(Applies only to Salt Creek
Elementary Dual Language
Program, Ridge Family
Center for Learning, John
Jay Elementary and
specifically assigned
students)
$55.00
Grades 1 - 5
$55.00
PRIOR YEAR BALANCE
TOTAL DUE
$
(Make your check payable
to SCHOOL DISTRICT 59)
$
-
$
-
$
-
$
-
$
-
$
-
$
-
$
-
Fees may be paid by credit card, check or cash. Credit card payments are only accepted on-line. Please go to www.ccsd59.org, click on PaySchool to pay on-line.
Checks must be made payable to: School District 59. Returned checks will be assessed a $25 fee. When you provide a check as payment, you authorize us either
to use information from your check to make a one-time electronic fund transfer from your account or to process the payment as a check transaction. When we
use information from your check to make an electronic funds transfer, funds may be withdrawn from your account as soon as the same day your payment is
received, and you will not receive your check back from your financial institution. Call 847/593-4348 if you have questions about electronic check collection or do
not want your payments collected electronically.
FOR OFFICE USE ONLY
Date ________________ Amount Paid __________________
By Check______ Check #__________
By Cash________
1. __________________________
3. _________________________
2. __________________________
4. _________________________
Macintosh HD:Users:DeMilio.Barb:Downloads:attachments (1):Instructional Materials Invoice Elem 1415.xls
Community Consolidated School District 59
TRANSPORTATION SERVICES
2123 S. ARLINGTON HEIGHTS ROAD • ARLINGTON HEIGHTS, IL 60005
847.593.4318 FAX 847.593.4410
2014-15 Kindergarten Transportation Information
Community Consolidated School District 59 allows kindergarten students free transportation if they reside 1 mile or more from
school OR residing in an area designated by the Board of Education as a “hazardous area” for walking (i.e. crossing a busy
roadway). If you have any questions about eligibility for free transportation please contact Transportation Services at 847/5934318.
Parents of kindergarten students who are requesting different bus stops than have been assigned must complete the enclosed
Transportation Request Form (T-42). Completion of this form will assist us to accurately assign your child to the appropriate
route. Pick-up and drop-off locations must be within the assigned school boundary and will be limited to the home or one
designated location, i.e., home and one baby-sitter. Alternating days of the week/multiple locations for pick-up and drop-off will
not be allowed. There will be no exceptions. This policy is for your child’s safety. This form must be completed and
forwarded to Transportation Services by July 1, 2014.
MORNING KINDERGARTEN STUDENTS:
Kindergarten students will be assigned a regular bus stop with other students from their school. They will get picked up from this
stop in the morning. At noontime, a bus will bring the morning students directly to their home or designated central location
within the apartment/mobile home complex. It is expected that an adult will meet the bus. The driver will not leave the student
unless an adult is seen or they see the student enter the home. Students without an escort will be returned to the child assigned
school.
AFTERNOON KINDERGARTEN STUDENTS:
At noontime, a bus will pickup the student from their home or designated central location within the apartment/mobile home
complex. The student is expected to be outside waiting for the bus at the designated time. After school, kindergarten students will
get off the bus at a regular bus stop with other students from their school. It is expected that someone will be there or at home to
meet the student, however the bus driver does not wait until they see an adult.
FULL DAY KINDERGARTEN STUDENTS:
Students who attend specialized full day programs will be assigned a regular bus stop with other students from their school. After
school, students will get off the bus at a regular bus stop with other students from their school. It is expected that someone will be
there or at home to meet the student, however the bus driver does not wait until they see an adult.
BUS CHANGES
Your student will be assigned a bus stop based on your home address. Any other pick-up or drop-off location, such as a daycare,
sitter, etc., must be submitted to Transportation by July 1, 2014 by filling out the Transportation Request Form. Other locations
must be within the attending school boundry. No changes will be accepted during the first two weeks of school. Parents
will be expected to provide transportation until changes are effective. Changes after the first two weeks will require a minimum of
three attendence days to process.
PAY TRANSPORTATION
Kindergarten students are not eligible to choose to pay for bus service due to the mid-day time constraint and space on the buses.
Please look for the District 59 August mailing of “Back to School” information which will include regular bus route and bus stop
information. You should receive this mailing by mid-August. A list of bus routes and stops will also be available at your home
school. If you have any questions, please contact Transportation Services at 847/593-4318.
FORM: T-43 01/13
Community Consolidated School District 59
TRANSPORTATION REQUEST FORM
School Year 20__/__
IMPORTANT: Complete this form if you require transportation services that are different from your assigned bus
stops. Any changes require a minimum of 3 days notice; changes at the beginning of the school year require 2 weeks
notice. These instructions will remain in place for the entire program listed below and cannot be changed without
further written authorization.
Submit this signed form to CCSD59 Transportation Dept., 2123 S. Arlington Heights Rd., Arlington Heights, IL 60005;
Fax 847-593-4410; For questions, please contact: 847-593-4318.
This request is being made for the following District 59 program:
___ Regular School Year
____ Summer School Program (Specify): ____________________________________
Student Name (Please Print): _________________________ School Program: ________________________________
______ Grade Level
______ Kindergarten/PreK AM ______ Kindergarten/PreK PM
Home Address: __________________________________________________ City: ___________________________
Home Phone: ___________________________ Language (if other than English): ______________________________
Check only ONE option for Pick-up and ONE option for Drop-off. All pick-up and drop-off sites must be located within District 59
boundaries. Alternating days of the week or multiple locations for pick-up or drop-off are not allowed.
Pick-up Information
Drop-off Information
____ No Bus Required, Parent will transport
____ No Bus Required, Parent will transport
____ Closest stop to home address
____ Closest stop to home address
____ Other: Please complete detailed information below:
____ Other: Please complete detailed information below:
Site Address: __________________________________
Site Address: __________________________________
_____________________________________________
_____________________________________________
Site Phone Number:_____________________________
Site Phone Number: _____________________________
Relationship to Student: __________________________
Relationship to Student: __________________________
Parent/Guardian Signature: __________________________________________________ Date: ________________
This section is for IEP (504) Students only: To be completed by District 59 Authorized Coordinators only.
The following information must be based on IEP (504) requirements.
Date for service to begin: ____________ Type of bus authorized: Lift: ________ Able to ride Gen Ed bus: ________
Type of service authorized: Curb to curb: _________ Curb to curb, no escort required: _______
Aide: _________
Special requirements: Child Securement: _______ Child’s weight: __________ Other: __________________________
LEA Coordinator Authorization Signature: ___________________________________________ Date: _____________
Transportation Department Use Only:
Date received: ________________ Route Assignment: ____________________ Effective Date: __________________
Contractor notification date: _____________________ Parent/school notification date: _________________________
Processed by: ___________________________________________________________________________________
Distribution: Original - Transp Dept; Copy - Ed. Svcs. T-42 Jan. 2013
COMMUNITY CONSOLIDATED SCHOOL DISTRICT 59
2123 S. Arlington Heights Road * Arlington Heights, IL 60005 #847-593-4300 (Phone), #847-593-4352 (Fax)
PARENT/GUARDIAN VERIFICATION OF STUDENT RESIDENCE
All students attending District 59 schools must be legal residents of the District.
Generally, Illinois law provides that the residence of a student is the same as the person who has legal custody of the student.
NOTICE: Registration of a student who is not a legal resident is a fraudulent act. Illinois law has made it a crime, punishable by imprisonment and fine, to knowingly or willfully
present any false information regarding the residency of a student for purposes of enabling that student to attend on a tuition-free basis or to knowingly enroll or attempt to enroll a
student on a tuition-free basis when the student is known to be a non-resident of the District. Board of Education policy authorizes the investigation of residency before or after
enrollment in accordance with Illinois law and may require additional information to be considered in determining residency. Parents/guardians who fraudulently register a student will be
charged tuition for the period the student had been in attendance. The District will seek prosecution to the full extent of the law of any person who the District believes has committed
any residency-related crime. Additionally, a civil lawsuit may be initiated by the District.
Student Name:
School Name:
A total of three (3) original documents from the categories below are required to prove residency (If Unable to Provide Use Form SR-5).
Category A:
One (1) Document Required
r
Most recent Real Estate Tax Bill
r
Mortgage Papers
r Signed and Dated Lease or Letter
from Manager or Proof of Last Month’s
Payment
IMPORTANT:
District 59 reserves the right to evaluate
the evidence present and merely
presenting the items listed below does
not guarantee admission.
Category B:
Two (2) Documents Required
r Current Homeowners/Renters
r Driver’s License or State ID
Insurance Policy and Premium Payment
Receipt
r
Vehicle Registration
r Voter Registration
r
Most Recent Cable or Credit Card Bill
r
Current Public Aid Card
Category C:
None of the Documents in Categories A &
B are Applicable Because:
r
Most Recent Gas, Electric and/or
Water Bill
Military Personnel
must provide one of the following
within 60 days after the date of
studentʼs initial enrollment:
r Postmarked Mail Addressed to Military Personnel
r
Mail Received at District Residence
r Lease Agreement for Occupancy
r
Receipt for Moving Company Services
Showing Current Address
r Proof of Ownership of Residence
r
Other ________________________
r
1. The student is homeless and eligible for enrollment under the Illinois Education for Homeless Children Act
r
2. The student is enrolling based on the determination of the Department of Children & Family Services (Attach DCFS Documentation)
I affirm that I am a resident of Community Consolidated School District 59 and that the information presented in this form is true, complete and accurate.
Printed Name of Parent / Guardian
Residency Materials Received By:
r
Referred for Further Review to:
SR-13 (REV. 12/13) Distribution: Studentʼs Temporary File
Signature of Parent / Guardian
Date
r
All Materials Supplied
r
Principal
r
Homeless Liaison
COMMUNITY CONSOLIDATED SCHOOL DISTRICT 59
2123 S. Arlington Heights Road * Arlington Heights, IL 60005
PHONE: 847-593-4300 * FAX: 847-593-4352
PERMANENT BIRTH RECORD
Parent/Guardian:
In accordance with Illinois law (325 ILCS 50/5, Missing Children’s Record Act) students enrolling in the district for
the first time, must provide within 30 days either:
a) an original certified student birth certificate, or
b) other reliable proof of the student’s identity and age (i.e. passport or visa) and an affidavit explaining the
inability to produce the certified original birth certificate.
Upon the failure of the person enrolling the student to provide the required evidence, the District will notify the
local law enforcement agency of such failure, and notify the person enrolling the student in writing that he/she has
10 additional days to comply, or the case will be referred to the local law enforcement agency for investigation.
Any affidavit presented which appears to be inaccurate or suspicious in form or content will immediately be
reported to the local law enforcement agency.
__________________________________________________________________ _________________________
Student’s Last Name
First
Middle
Date of Birth
Place of Birth (City, State, Country)__________________________________________________________
Proof of Birth and Age (mark one and attach copy of document to this form):

Birth Certificate
State_________________
Number__________________________________

Passport
Country______________
Number__________________________________

Visa
Country______________
Number__________________________________

Other______________________________________________________________
I am unable to provide an original certified birth certificate for the above named student because:
____________________________________________________________________________________________
____________________________________________________________________________________________
_______________________________________ ____________________________________ ________________
Name of Parent/Guardian (PRINTED)
Signature of Parent/Guardian
Date
..............................................................................................................................................................................................
(for office use only)
Documentation Requirement:

Met

Not Met
Verified by:_______________________________ School __________________ Date___________
SR-11
(Rev. Feb. 2014)
Distribution: Student’s Temporary File
Community Consolidated School District 59
ELEMENTARY
AUTHORIZATION FOR INTERNET AND ELECTRONIC NETWORK ACCESS
Parent/Guardian Signature Page for Students New to District 59
2014/15
Student Name ______________________________________
Student I.D._______________
School
Grade Level_______________
______________________________________
This authorization is required annually. Please complete and return this form to your school.
The District’s Electronic Network provides Internet and other electronic access in support of education
and/or research. The goal in providing this access is to promote educational excellence by facilitating
resource sharing, innovation, productivity, and communication. Parents (guardians) must annually grant
permission for their student(s) to access these resources. Students must also agree to abide by the
District’s and school’s electronic network rules and regulations. Violation of applicable policies,
regulations or procedures may result in the loss of the privilege to use this resource, District disciplinary
action, and/or referral to law enforcement.
The District takes precautions to prevent access to materials that may be defamatory, inaccurate,
offensive, or otherwise inappropriate in the school setting. Each District computer with Internet access
has a filtering device that blocks entry to visual depictions that are (1) obscene, (2) pornographic, or (3)
harmful or inappropriate for students, as defined by the Children’s Internet Protection Act and as
determined by the Superintendent or designee. However, it is impossible to control all material and a
user may discover inappropriate material. Ultimately, staff members and/or parent(s)/guardian(s) are
responsible for setting and conveying the standards that their students, children, or wards should follow.
To that end, the District supports and respects each individual’s right to decide whether or not to
authorize electronic network access.
Before signing this Authorization, parents (guardians) are expected to read Board Policy 6.235:
Instruction, Access to Electronic Networks; and Administrative Regulation 6.235-R2: Student’s Use of
Electronic Networks.
PARENT (GUARDIAN): Please complete the following.
YES NO I authorize that my child be allowed access to the District’s Internet and Electronic Networks.
(Please circle your response).
I have read this Authorization for Internet and Electronic Network Access. I understand that access
is designed for educational purposes and that the District has taken precautions to eliminate
controversial material. However, I also recognize it is impossible for the District to restrict access to all
controversial and inappropriate materials. I will hold harmless Community Consolidated School District
59, its employees, agents, or Board of Education members, for any harm caused by materials or software
obtained via the network. I accept full responsibility for supervision if and when my child’s use is not in
a school setting. I have discussed the terms of this Authorization with my child.
Parent/Guardian Name (Please print) ______________________________________________
Parent/Guardian Signature ____________________________________Date______________
SR-38A
NEW STUDENT REGISTRATION and EMERGENCY CONTACT FORM - CCSD59
Directions: Print & Complete Both Sides. Shaded Section at Top is for Office Use Only.
Student Other ID:
Student State ID:
Student Last Name:
School:
Student First Name:
Grade:
Student Middle Name:
Birth Date: __ __
Gender:
Street Address:
Apt. / Lot / Unit #:
City & Zip Code:
Complex / Mobile Home Park Name:
Primary Phone Number:
Has Your Student Been Enrolled in
District 59 Before? :
Date Your Student Entered a U.S. School:
(Month / Year)
__ __
Name of Last School Attended & State:
Is Your Child Receiving Any Special Services?
/ __ __ __ __
Bilingual
9 Digit Medicaid Number:
Country of Birth:
State of Birth:
City of Birth:
ESL
(Voluntary & Optional)
Military Service
Information:
Special Education
/ __ __ / __ __
Male
Yes
Female
No
If Yes, Which D59 School/s and What Year/s?
Other:
I am a member of the United States Armed Forces
I am on active duty / expected to be deployed to active duty during the school year
Custodial Parent / Guardian Information
Title:
First Name:
Relationship to Student:
Language Preference:
Title:
Last Name:
Father
English
Mother
Spanish
Step-Father
Polish
First Name:
Relationship to Student:
Language Preference:
Step-Mother
Gujarati
Work Phone & Extension:
Guardian
Other: __________________
English
Mother
Spanish
Step-Father
Polish
Step-Mother
Gujarati
Email Address:
Custody:
Yes
No
Lives With:
Work Phone & Extension:
Last Name:
Father
Cell Phone:
Guardian
Other: __________________
Yes
No
Cell Phone:
Email Address:
Custody:
Yes
No
Lives With:
Yes
No
Office Use Only
Title:
First Name:
Relationship to Student:
Father
Mother
Language Preference:
English
Spanish
SR-39 (Revised12/13)
Work Phone & Extension:
Last Name:
Step-Father
Polish
Step-Mother
Gujarati
Guardian
Other: __________________
Cell Phone:
Email Address:
Custody:
Yes
No
Lives With:
Yes
No
Local Persons to Call in an EMERGENCY if Parents/Guardians Cannot Be Reached - List at least Two (2) People
First and Last Names:
Relationship:
Language Spoken:
Phone Number:
1
2
3
4
List ALL other Studentʼs Siblings (Brother/s or Sister/s) in immediate family enrolled in District 59
First Name:
Last Name:
Name of School Attending:
1
2
3
4
5
Parent/Guardian Name (Please Print):
Parent/Guardian Signature:
Grade:
Age:
COMMUNITY CONSOLIDATED SCHOOL DISTRICT 59
2123 S. Arlington Heights Road * Arlington Heights, IL 60005
847-593-4300
ANNUAL STUDENT HEALTH FORM
20 ___ - 20 ___ SCHOOL YEAR
Student: ____________________________________________ Birth date ______________________
(last)
(first)
Grade _________________ Sex ________ School _________________________________________
Annual Health History Update
YES
NO
1. Does this child have:
Allergies to food, medications or insect stings
______
______
Asthma
______
______
Any chronic illness
______
______
A seizure disorder
______
______
Any physical limitations
______
______
Diabetes
______
______
Explain: __________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
2. During the past 12 months has this child been:
YES
NO
Hospitalized (include surgeries)
______
______
Seriously injured
______
______
Explain: __________________________________________________________________________________________
_________________________________________________________________________________________________
YES
NO
3. Does this child take medication on a regular basis?
______
______
Explain: __________________________________________________________________________________________
_________________________________________________________________________________________________
(If medications, inhaler or glucose monitoring, etc., needs to be done at school, please refer to the appropriate forms “Medication Guidelines” H24; “School Medication Authorization” H-25; “Hold Harmless and Indemnification for the Self-Administration of Asthma Medication and/or
Possession of an Epinephrine Auto-Injector (Epi-Pen®)” H-26. Complete proper form(s)and return it to the school nurse.)
YES
NO
4. Are there any other health concerns that the nurse/teacher should be
aware of?
______
______
Explain: __________________________________________________________________________________________
_________________________________________________________________________________________________
Physician Contact Information
Physician Name: __________________________________Phone:_____________________________
Name of Practice: ____________________________________________________________________
Physician Address: ___________________________________________________________________
Parent(Guardian) Name (please print):_______________________________________________________
Parent (Guardian) Signature____________________________________Date_______________________
Return to your child’s school health office.
H-103 (Rev. 12/13) Distribution: health file
COMMUNITY CONSOLIDATED SCHOOL DISTRICT 59
2123 S. Arlington Heights Road * Arlington Heights, IL 60005
PHONE: 847-593-4300 * FAX: 847-593-4352
HOME LANGUAGE SURVEY
All students new to the district must have this survey completed and signed by a
parent/guardian in accordance with state regulations (23 Illinois Administrative Code Part 228).
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.
__________________________________________ ________________  Male  Female
Student’s Last Name
First
Middle
Date of Birth
School______________________________ SIS ID # _____________________________
1.
Is a language other than English spoken in your home?
a. Yes ____ What language?_________________________________
b. No ____
2.
Does your child speak a language other than English?
a. Yes ____ What language? _________________________________
b. No ____
If the answer to either question is yes, the law requires the school to assess your child’s English
language proficiency.
Parent/Guardian (Print)____________________Relationship to Student____________ Date__________
Parent/Guardian Signature______________________Staff Member who Registered Child___________
(For Office Use Only)
Language________________________ Language Code #________ Grade Assignment__________
Request for Language Assessment from ELL Personnel:  Yes
SR-12 (Rev. 12/2013) Distribution: Student’s Temporary/Cum File
 No
Date______________
Page 1 of 1
COMMUNITY CONSOLIDATED SCHOOL DISTRICT 59
2123 S. Arlington Heights Road * Arlington Heights, IL 60005
PHONE: 847-593-4300 * FAX: 847-593-4352
ANKIETA DOTYCZĄCA JĘZYKA OJCZYSTEGO
Przepisy Stanu Illinois wymagają wypełnienie i złożenia podpisu na kwestionariuszu
dotyczącym każdego nowego ucznia w okręgu szkolnym. (23 Illinois Administrative Code Part
228).Informacje te dotyczą uczniów, którzy w domu rodzinnym posługują się innym językiem niż
angielskim. Jednocześnie ankieta ta pomaga nam zidentyfikować tych uczniów, którzy powinni
być testowani w celu sprawdzenia ich umiejętności w nauce języka angielskiego.
________________________________________ ________________  Chłopak Dziewczynka
Nazwisko ucznia
Imię
Drugie imię
Data urodzenia
Szkoła______________________________ SIS ID # _____________________________
1.
Czy ktoś w domu posługuje się innym językiem niż angielskim?
a. Tak ____ W jakim języku?_________________________________
b. Nie ____
2.
Czy Państwa dziecko mówi w języku innym niż angielskim?
a. Tak ____ Jaki to język? _________________________________
b. Nie ____
Jeśli odpowiedż jest pozytywna do jednego z powyżej podanych pytań, prawo wymaga
przeprowadzenia testu z zakresu znajomości i umiejętności posługiwania się językiem
angielskim.
Rodzice/ Opiekunowie (Drukuj)____________________Pokrewieństwo____________ Data__________
Podpis Rodziców lub Opiekunów______________________Osoba rejestrująca ucznia___________
(For Office Use Only)
Language________________________ Language Code #________ Grade Assignment__________
Request for Language Assessment from ELL Personnel:  Yes
SR-12 (Rev. 12/2013) Distribution: Student’s Temporary/Cum File
 No
Date______________
Page 1 of 1
Community Consolidated School District 59
U.S. Department of Education Race and Ethnicity Data Standards
DATA COLLECTION FORM
Student’s Name:
___School___________________________
IMPORTANT INFORMATION: The U.S. Department of Education requires this form to be
completed upon a student’s enrollment into a school district. The data is used in
reporting and analyzing State-required test results by race and ethnicity. The
information will not be used to check immigration status, and the confidentiality of the
individual student information will be protected.
INSTRUCTIONS: This form is to be filled out by the student’s parents or guardians, and both
questions must be answered. Part A asks about the student’s ethnicity (refers to culture and
language) and Part B asks about the student’s race (refers to geographic or national origin).
PLEASE NOTE: If you decline to respond to either question, the school district is required to
provide the missing information by observer identification.
Part A. Is this student Hispanic/Latino? (A person of Cuban, Mexican, Puerto Rican, South
or Central American, or other Spanish culture or origin, regardless of race.)
Choose only one.
! No, not Hispanic/Latino
! Yes, Hispanic/Latino
The question above is about ethnicity, not race. No matter which answer you selected,
continue to respond to the question below by marking one or more boxes to indicate
what you consider this student’s race to be.
Part B. What is the student’s race? Choose one or more.
! American Indian or Alaska Native (A person having origins in any of the original
peoples of North and South America, including Central America, and who maintains
tribal affiliation or community attachment.)
! Asian (A person having origins in any of the original peoples of the Far East,
Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China,
India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and
Vietnam.)
! Black or African American (A person having origins in any of the black racial
groups of Africa.)
! Native Hawaiian or Other Pacific Islander (A person having origins in any of the
original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.)
! White (A person having origins in any of the original peoples of Europe, the Middle
East, or North Africa.)
_________________________________________
Parent/Guardian Signature
Office Use Only:
Observer Identification
SR-36 1/1 School Year
________________________
Date
Check box if Yes
Distribution: Original – Student Temporary File (cumulative file)
COMMUNITY CONSOLIDATED SCHOOL DISTRICT 59
2123 S. Arlington Heights Road * Arlington Heights, IL 60005
PHONE: 847-593-4300 * FAX: 847-593-4352
Publication of Student Photographs, Audiotapes, Videotapes, Yearbook or Works
The voice, image, photographs and/or audio or video recordings of students may be used in various District or District-related
publications, including without limitation school yearbooks, school newspapers and newsletters, District publications and
news releases, presentations at professional conferences and Board of Education meetings, District television productions,
and the District’s web and social media sites, may also be released for authorized non-District uses, including without
limitation, school parent group publications, local newspapers, magazines, television, and/or other educational entities, unless
you check the box below.
Please be advised that even if you check the box below, the District reserves the right to release or publish photographs or
videotapes that do not concern or directly relate to your student but where your student appears in the background. Parent
authorization is not required for the release or publication of such background shots of students. Furthermore, whether taken
by the District or others, videotapes, audiotapes, or photographs of students participating in extracurricular activities (e.g.,
athletic events, theatrical productions), which by their very nature involve exposure to the public, may also be released or
published without authorization from parents.
 I do NOT allow the school to release or publish my child’s voice, image, works, photographs or audio or video
recordings as described in paragraph 1 of this form. I understand that background and extracurricular photographs,
videotapes, or audiotapes may be released or published as described in paragraph 2 of this form even if I check this box.
I further understand that this means my child will not be featured in publicity about the achievements or activities of my
child or my child’s classmates or school.
_______________ _____________________
Print Student Name Student ID Number
_________________________
Signature of Parent/Guardian
____________
Date
This consent is valid for the current school year. I may revoke this consent at any time by notifying in writing the
Building Principal. This consent does NOT apply to security footage taken on school busses or property, Security
footage may be released and reviewed to the extent permitted under the law.
SR_37 (Revised 1/24/14) Distribution: Student’s Temporary File
COMMUNITY CONSOLIDATED SCHOOL DISTRICT 59
2123 S. Arlington Heights Road * Arlington Heights, IL 60005
PHONE: 847-593-4300 * FAX: 847-593-4352
IMPORTANT INFORMATION REGARDING
ILLINOIS CERTIFICATE OF CHILD HEALTH EXAMINATION FORM
Dear Parent/Guardian,
The Illinois School Code requires that all children entering kindergarten or the first grade, or
enrolling in an Illinois school for the first time, regardless of the student’s grade (including early
childhood, special education, and student’s transferring into Illinois), have a physical
examination within one year prior to entry into school. There must also be documented evidence
that each child has received all required immunizations.
Attached is a Certificate of Child Health Examination form. Please be sure the following
information is completed on this form before it is returned to school:
- The student’s name and information should be entered on both sides of the exam form.
- Immunization History must include specific dates. A health care provider’s signature is
required to verify the immunization dates.
- The Health History (on the back) must be completed and signed by a parent/guardian.
- The physical exam must be completed, dated, and signed by a physician, nurse practitioner or
physician’s assistant.
- Approval to participate in Physical Education and Interscholastic Sports near the bottom of
the page must be checked by the physician. Modifications must be specified.
The only exception to this requirement is based on religious objection or medical
contraindication for your child. However, proper documented evidence must be submitted to
your child’s school health office.
If, for any reason, you are unable to comply with the state requirement, please contact your
child’s school health office as soon as possible.
We appreciate your cooperation in this matter.
Denise M. Webster, RN, CSN
Health Coordinator, District #59
Enclosure: Certificate of Child Health Examination
H-30
(Revised 1/11) Distribution: Parent/Guardian
State of Illinois
Eye Examination Report
Illinois law requires that proof of an eye examination by an optometrist or physician who provides complete eye examinations be
submitted to the school no later than October 15 of the year the child is first enrolled or as required by the school for other children.
The examination must be completed within one year prior to October 15 of the year the child enters an Illinois school.
Student Name ________________________________________________________________________________________________
(Last)
(First)
(Middle Initial)
Birth Date ____________________ Sex _____ Grade _______
(Month/Day/Year)
Parent or Guardian ____________________________________________________________________________________________
(Last)
(First)
Phone ______________________________
(Area Code)
Address _____________________________________________________________________________________________________
(Number)
(Street)
(City)
(ZIP Code)
County ____________________________________________
To Be Completed By Examining Doctor
Case History
Date of Exam ________________
Ocular History:
! Normal
or Positive for _______________________________
Medical History:
! Normal
or Positive for _______________________________
Drug Allergies:
! NKDA
or Allergic to ________________________________
Other Information _____________________________________________________________________________________________
Examination
Refraction:
Distance
Unaided Visual Acuity
Best Corrected Visual Acuity
Right
20/
20/
Left
20/
20/
Both
20/
20/
Was refraction performed with cycloplegic agents?
External Exam (eye and adnexa)
Internal Exam (media, lens, fundus, etc.)
Neurological Integrity (pupils)
Binocular Function (stereopsis)
Accommodation and Vergence
Color Vision
IOP (glaucoma)
Oculomotor Assessment
Other _________________________
Diagnosis
! Normal
! Myopia
! Hyperopia
Near
Both
20/
20/
! Yes
Normal
!
!
!
!
!
!
!
!
!
! Astigmatism
! No
Abnormal
!
!
!
!
!
!
!
!
!
! Strabismus
Not Able to Assess
!
!
!
!
!
!
!
!
!
Comments
__________
__________
__________
__________
__________
__________
__________
__________
__________
! Amblyopia
Other _______________________________________________________________________________________________________
Continued on back
Page 1
H-67
Revised 12/10 Distribution: Health File
State of Illinois
Eye Examination Report
Recommendations
1. Corrective Lenses: ! No ! Yes, glasses should be worn for:
! Constant Wear ! Near Vision ! Far Vision
! May Be Removed for Physical Education
2. Preferential seating recommended:
! No
! Yes
Comments ________________________________________________________________________________________________
_________________________________________________________________________________________________________
3. Recommend re-examination:
! 3 months
! 6 months
! 12 months
! Other ____________________________________
4. _________________________________________________________________________________________________________
5. _________________________________________________________________________________________________________
Print name___________________________________________
Optometrist or Physician who provides eye examinations
Address ____________________________________________
Consent of Parent or Guardian
I agree to release the above information on my child
or ward to appropriate school or health authorities.
____________________________________________
Phone
____________________________________________
(Parent or Guardian’s Signature)
Signature ____________________________________________
Optometrist or Physician who provides eye examinations
(Source: Amended at 32 Ill. Reg. _________, effective ___________)
Page 2
H-67
Printed by Authority of the State of Illinois
5/08
Revised 12/10 Distribution: Health File
IISG08-1048
Illinois Department of Public Health
PROOF OF DENTAL EXAMINATION FORM
To be completed by the parent (please print):
Student’s Name: Last
First
Middle
Birth Date:
Address: Street
City
ZIP Code
Telephone:
(Month/Day/Year)
/
Name o f School:
Grade Level:
Gender:
Male
Parent or Guardian:
/
Female
Address (o f parent/guardian):
To be completed by dentist:
Oral Health Status (check all that apply)
Yes
No Dental Sealants Present
Yes
No Caries Experience / Restoration History — A filling (temporary/permanent) OR a tooth that is missing because it
st
was extracted as a result of caries OR missing permanent 1 molars.
Yes
No Untreated Caries — At least 1/2 mm of tooth structure loss at the enamel surface. Brown to dark-brown coloration of the
walls of the lesion. These criteria apply to pit and fissure cavitated lesions as well as those on smooth tooth surfaces. If retained
root, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are considered
sound unless a cavitated lesion is also present.
Yes
No Soft Tissue Pathology
Yes
No Malocclusion
Treatment Needs (check all that apply)
Urgent Treatment — abscess, nerve exposure, advanced disease state, signs or symptoms that include pain, infection, or swelling
Restorative Care — amalgams, composites, crowns, etc.
Preventive Care — sealants, fluoride treatment, prophylaxis
Other — periodontal, orthodontic
Please note____________________________________________________________________________
Signature of Dentist _______________________________________ Date _________________________
Address ______________________________________________ Telephone _______________________
Street
City
ZIP Code
Illinois Department of Public Health, Division of Oral Health, 535 W. Jefferson St., Springfield, IL 62761
217-785-4899 • TTY (hearing impaired use only) 800-547-0466 • www.idph.state.il.us
Printed by Authority of the State of Illinois
P.O.#346085 5M 10/05
H-11
(Rev. 11/05)
Distribution: health file
FOR USE IN DCFS LICENSED CHILD CARE FACILITIES
CFS 600
Rev 2/2013
State of Illinois
Certificate of Child Health Examination
Student’s Name
Birth Date
Last
First
Address
Middle
Street
City
Sex
Race/Ethnicity
School /Grade Level/ID#
Month/Day/Year
Parent/Guardian
Zip Code
Telephone # Home
Work
IMMUNIZATIONS: To be completed by health care provider. Note the mo/da/yr for every dose administered. The day and month is required if you cannot
determine if the vaccine was given after the minimum interval or age. If a specific vaccine is medically contraindicated, a separate written statement must be
attached explaining the medical reason for the contraindication.
1
MO DA YR
2
MO DA YR
3
MO DA YR
4
MO DA YR
5
MO DA YR
TdapTdDT
TdapTdDT
TdapTdDT
TdapTdDT
TdapTdDT
TdapTdDT
 IPV  OPV
 IPV  OPV
 IPV  OPV
 IPV  OPV
 IPV  OPV
 IPV  OPV
Vaccine / Dose
6
MO DA YR
DTP or DTaP
Tdap; Td or Pediatric
DT (Check specific type)
Polio (Check specific
type)
Hib Haemophilus
influenza type b
Hepatitis B (HB)
COMMENTS:
Varicella
(Chickenpox)
MMR Combined
Measles Mumps. Rubella
Measles
Single Antigen
Vaccines
Rubella
Mumps
Pneumococcal
Conjugate
Other/Specify
Meningococcal,
Hepatitis A, HPV,
Influenza
Health care provider (MD, DO, APN, PA, school health professional, health official) verifying above immunization history must sign below. If adding dates
to the above immunization history section, put your initials by date(s) and sign here.)
Signature
Title
Date
Signature
ALTERNATIVE PROOF OF IMMUNITY
Title
Date
1. Clinical diagnosis is acceptable if verified by physician.
*(All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence.)
*MEASLES (Rubeola) MO DA YR MUMPS MO DA YR VARICELLA MO DA YR
Physician’s Signature
2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official.
Person signing below is verifying that the parent/guardian’s description of varicella disease history is indicative of past infection and is accepting such history as documentation of disease.
Date of Disease
Signature
3. Laboratory confirmation (check one) Measles
Lab Results
Date
Title
Mumps
MO
DA
Rubella
Date
Hepatitis B
Varicella
(Attach copy of lab result)
YR
VISION AND HEARING SCREENING BY IDPH CERTIFIED SCREENING TECHNICIAN
Date
Code:
Age/
Grade
R
L
R
L
R
L
R
L
R
L
R
L
Vision
Hearing
IL444-4737 (R-02-13)
(COMPLETE BOTH SIDES)
R
L
R
L
R
L
P = Pass
F = Fail
U = Unable to test
R = Referred
G/C =
Glasses/Contacts
Printed by Authority of the State of Illinois
Sex
Birth Date
Last
First
HEALTH HISTORY
ALLERGIES
Middle
School
Grade Level/ ID
#
Month/Day/ Year
TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDER
MEDICATION (List all prescribed or taken on a regular basis.)
(Food, drug, insect, other)
Diagnosis of asthma?
Child wakes during night coughing?
Yes
Yes
No
No
Loss of function of one of paired
organs? (eye/ear/kidney/testicle)
Yes
No
Birth defects?
Yes
No
No
Yes
No
Hospitalizations?
When? What for?
Yes
Developmental delay?
Blood disorders? Hemophilia,
Sickle Cell, Other? Explain.
Diabetes?
Yes
No
Yes
No
Yes
No
Surgery? (List all.)
When? What for?
Serious injury or illness?
Yes
No
Head injury/Concussion/Passed out?
Yes
No
TB skin test positive (past/present)?
Yes*
Seizures? What are they like?
Yes
No
TB disease (past or present)?
Yes*
No *If yes, refer to local health
department.
No
Heart problem/Shortness of breath?
Yes
No
Tobacco use (type, frequency)?
Yes
No
Heart murmur/High blood pressure?
Yes
No
Alcohol/Drug use?
Yes
No
Yes
No
Family history of sudden death
before age 50? (Cause?)
Yes
No
Dizziness or chest pain with
exercise?
Eye/Vision problems? _____ Glasses  Contacts  Last exam by eye doctor ______
Other concerns? (crossed eye, drooping lids, squinting, difficulty reading)
Ear/Hearing problems?
Yes
No
Bone/Joint problem/injury/scoliosis?
Yes
 Bridge
 Plate Other
Information may be shared with appropriate personnel for health and educational purposes.
Parent/Guardian
No
PHYSICAL EXAMINATION REQUIREMENTS
 Braces
Dental
Signature
Date
Entire section below to be completed by MD/DO/APN/PA
HEAD CIRCUMFERENCE if < 2-3 years old
HEIGHT
WEIGHT
BMI
B/P
DIABETES SCREENING (NOT REQUIRED FOR DAY CARE) BMI>85% age/sex Yes No And any two of the following: Family History Yes  No 
Ethnic Minority Yes No  Signs of Insulin Resistance (hypertension, dyslipidemia, polycystic ovarian syndrome, acanthosis nigricans) Yes No  At Risk Yes  No 
LEAD RISK QUESTIONNAIRE Required for children age 6 months through 6 years enrolled in licensed or public school operated day care, preschool, nursery school
and/or kindergarten. (Blood test required if resides in Chicago or high risk zip code.)
Questionnaire Administered ? Yes  No 
Blood Test Indicated? Yes  No 
Blood Test Date
Result
TB SKIN OR BLOOD TEST Recommended only for children in high-risk groups including children immunosuppressed due to HIV infection or other conditions, frequent travel to or born
No test needed 
Test performed 
in high prevalence countries or those exposed to adults in high-risk categories. See CDC guidelines.
Skin Test: Date Read
/ /
Result: Positive  Negative 
mm ______________
Blood Test: Date Reported
/ /
Result: Positive  Negative 
Value ______________
Date
LAB TESTS (Recommended)
Results
Date
Hemoglobin or Hematocrit
Urinalysis
Sickle Cell (when indicated)
Developmental Screening Tool
SYSTEM REVIEW
Skin
Ears
Endocrine
Gastrointestinal
Normal Comments/Follow-up/Needs
Eyes
Results
Normal Comments/Follow-up/Needs
Amblyopia Yes
LMP
Genito-Urinary
No
Nose
Neurological
Throat
Musculoskeletal
Mouth/Dental
Spinal Exam
Cardiovascular/HTN
Nutritional status
 Diagnosis of Asthma
Respiratory
Mental Health
Currently Prescribed Asthma Medication:
 Quick-relief medication (e.g. Short Acting Beta Agonist)
 Controller medication (e.g. inhaled corticosteroid)
NEEDS/MODIFICATIONS required in the school setting
Other
DIETARY Needs/Restrictions
SPECIAL INSTRUCTIONS/DEVICES e.g. safety glasses, glass eye, chest protector for arrhythmia, pacemaker, prosthetic device, dental bridge, false teeth, athletic support/cup
MENTAL HEALTH/OTHER
Is there anything else the school should know about this student?
If you would like to discuss this student’s health with school or school health personnel, check title:
 Nurse
 Teacher
 Counselor
 Principal
EMERGENCY ACTION needed while at school due to child’s health condition (e.g. ,seizures, asthma, insect sting, food, peanut allergy, bleeding problem, diabetes, heart problem)?
Yes  No  If yes, please describe.
On the basis of the examination on this day, I approve this child’s participation in
PHYSICAL EDUCATION
Print Name
Address
Yes 
No 
Modified 
(If No or Modified please attach explanation.)
INTERSCHOLASTIC SPORTS
(MD,DO, APN, PA)
Signature
Phone
(Complete Both Sides)
Yes 
No 
Date
Limited 
Community Consolidated School District 59
ELK GROVE TOWNSHIP SCHOOLS • BOARD OF EDUCATION AND ADMINISTRATIVE OFFICES
2123 S. ARLINGTON HEIGHTS ROAD • ARLINGTON HEIGHTS, ILLINOIS 60005
PHONE 847/593-4300 • FAX 847/593-4352
REQUEST FOR STUDENT RECORDS
Student’s Last Name
First Name
Request Date
Middle
Birthdate
State
Zip
Name of School or Agency Releasing Records
Address
City
Contact Person
Fax Number
Student Permanent Records
Basic identifying information.
Academic transcripts, attendance records, and medical
records.
Student Temporary Records
Family background information, group and individual test scores, teacher
evaluations, psychological evaluations, achievement level test results, extracurricular activities, disciplinary information, and special education records.
District 59 requests the above checked records of this student be forwarded to the school checked below.
ELEMENTARY SCHOOLS
Brentwood
260 Dulles Road
Des Plaines, IL 60016
(847) 593-4401
Fax: (847) 593-7184
Admiral Byrd
265 Wellington Avenue
Elk Grove Village, IL 60007
(847) 593-4388
Fax: (847) 593-7188
Clearmont
280 Clearmont Drive
Elk Grove Village, IL 60007
(847) 593-4372
Fax: (847) 593-7194
Devonshire
1401 S. Pennsylvania Avenue
Des Plaines, IL 60018
(847) 593-4398
Fax: (847) 593-7183
Forest View
1901 Estates Drive
Mount Prospect, IL 60056
(847) 593-4359
Fax: (847) 593-4360
Robert Frost
1308 S. Cypress
Mount Prospect, IL 60056
(847) 593-4378
Fax: (847) 593-4365
John Jay
1835 Pheasant Trail
Mount Prospect, IL 60056
(847) 593-4385
Fax: (847) 593-8656
Juliette Low
1530 Highland Avenue
Arlington Heights, IL 60005
(847) 593-4383
Fax: (847) 593-7291
Ridge Family Center for Learning
650 Ridge Avenue
Elk Grove Village, IL 60007
(847) 593-4070
Fax: (847) 593-4075
Ira R. Rupley
305 East Oakton Street
Elk Grove Village, IL 60007
(847) 593-4353
Fax: (847) 593-4405
Salt Creek Elementary School
65 Kennedy Boulevard
Elk Grove Village, IL 60007
(847) 593-4375
Fax: (847) 593-7390
JUNIOR HIGH SCHOOLS
Friendship
550 Elizabeth Lane
Des Plaines, IL 60018
(847) 593-4350
Fax: (847) 593-7182
Grove
777 Elk Grove Boulevard
Elk Grove Village, IL 60007
(847) 593-4367
Fax: (847) 472-3001
Holmes
1900 Lonnquist Boulevard
Mount Prospect, IL 60056
(847) 593-4390
Fax: (847) 593-7386
SPECIAL EDUCATION
Special Education Department
2123 S. Arlington Heights Road, Arlington Heights, IL 60005 (847) 593-4335 Fax: (847) 593-4352
Parent/Guardian Signature
I authorize School District 59 to obtain information concerning the above named student.
Date
School Authorized Signature
Date
SR-9 (Rev. 8/07)
Distribution: Student’s Previous School, Temporary File