List All Children in Same Household PLEASE PRINT

HOUSEHOLD REGISTRATION

Household information is collected at the first registration site and shall be filled out once by the parent/guardian.

Planned Starting Date:

List all Children in Same Household PLEASE PRINT

1st Child’s LEGAL Name: ______First Middle Last Date of Birth: ______Grade: ______ Female  Male Verified by: ______2nd Child’s LEGAL Name: ______First Middle Last Date of Birth: ______Grade: ______ Female  Male Verified by: ______3rd Child’s LEGAL Name: ______First Middle Last Date of Birth: ______Grade: ______ Female  Male Verified by: ______4th Child’s LEGAL Name: ______First Middle Last Date of Birth: ______Grade: ______ Female  Male Verified by: ______Use a separate piece of paper for any additional students. Primary Household (This is the address where the above children reside)

Physical Address: ______Number Street Apt/Unit/Lot Verified by: ______City State Zip Township/Village/City of Mailing Address: ______(If different) Number Street Apt/Unit/Lot ______City State Zip Township/Village/City of

Home Phone: (____)______ (Check if unlisted)

Parent or Guardian (This is the primary parent/guardian for the children listed above.)

Name: ______First Middle Last Preferred contact method: Employer Name: ______Work Phone: (____)______ Web Portal  Email Cell Phone: (____)______Hm Email Address: ______ By Mail  Only by Mail Wk Email Address: ______Relation to Student:  Father  Mother  Step-father  Step-mother  Foster father  Foster mother  Legal Guardian (by court—attach form)  Other (attach form and specify): ______Parent or Guardian (This is either the second parent/guardian or a step-parent living in the household.)

Name: ______First Middle Last Preferred contact method: Employer Name: ______Work Phone: (____)______ Web Portal  Email  By Mail Cell Phone: (____)______Hm Email Address: ______ Only by Mail Wk Email Address: ______Relation to Student:  Father  Mother  Step-father  Step-mother  Foster father  Foster mother  Legal Guardian (by court—attach form)  Other (attach form and specify): ______Secondary Household (This section should be completed if both parents do not live in the Primary Household or split custody of child(ren.) Physical Address: ______Number Street Apt/Unit/Lot ______City State Zip Township/Village/City of Mailing Address: ______(If different) Number Street Apt/Unit/Lot ______City State Zip Township/Village/City of Home Phone: (____)______ (Check if unlisted)

Parent or Guardian (This is the primary parent/guardian for the children listed above.)

Name: ______First Middle Last Preferred contact method: Employer Name: ______Work Phone: (____)______ Web Portal  Email Cell Phone: (____)______Email Address: ______ By Mail  Only by Mail Relation to Student:  Father  Mother  Step-father  Step-mother  Foster father  Foster mother  Legal Guardian (by court—attach form)  Other (attach form and specify): ______

Parent or Guardian (This is either the second parent/guardian or a step-parent living in the household.)

Name: ______First Middle Last Preferred contact method: Employer Name: ______Work Phone: (____)______ Web Portal  Email Cell Phone: (____)______Email Address: ______ By Mail  Only by Mail Relation to Student:  Father  Mother  Step-father  Step-mother  Foster father  Foster mother  Legal Guardian (by court—attach form)  Other (attach form and specify): ______

Emergency Contacts (Place a checkmark next to emergency contacts who may check the student out of school.) Name Home Phone Work Phone Cell Phone Other Phone    