NEW STUDENT REGISTRATION – CRYSTAL LAKE ELEMENTARY DISTRICT 47

Legal Last Name: Legal First Name: Full Middle Name: ----------------------------------------------------------------------------------------------------------------------------------------------------------------

Gender: Date of Birth: Birth City: Birth State:---------------------------------------------------------------------------------------------------------------------------------------------------------------

Birth Country if other than US: Primary Phone #: Type: --------------------------------------------------------------------------------------------------------------------------------------------------------------- Home Address: City: Zip Code: --------------------------------------------------------------------------------------------------------------------------------------------------------------- Subdivision: Is the mailing address the same? -------------------------------------------------------------------------------------------------------------------------------------------------------------- If no, enter mailing address: -------------------------------------------------------------------------------------------------------------------------------------------------------------- School or pre-school last attended: Number of Years: -------------------------------------------------------------------------------------------------------------------------------------------------------------

SPECIAL EDUCATION Has your child ever been enrolled in or recommended for Special Education services? Yes No If yes, what type of Special Education services? __________________________________________________Do you have a copy of the current IEP? Yes No No longer receives services Does your child have any physical needs which require special attention? Yes No If yes, please identify: Speech Vision Hearing Other : ___________________________

LANGUAGE SERVICES (used to determine whether your child requires English as a Second Language service) Has your child received English as a Second Language (ESL/ELL and or Bilingual) support services in any previous school district in the United States? Yes No Crystal Lake Elementary District 47 attempts to send information to parents in both English and Spanish, however that is not always possible. If a document is available in Spanish, would you prefer to receive it that way? Yes No

Student ID: ____________ Date: _______________ Grade: ____________

L: Y N BC : Y N _________________

School: ______________

Start Date:________________

(FOR OFFICE USE ONLY)

For Office Use Only: LNG

SE SCAN PHOTO: Y N SIS PV INIT________

STUDENT INFORMATIONThe Missing Child's Act 84-1430 requires child's "official" birth certificate upon registering a new student to District 47

DUAL LANGUAGE SERVICES (Note: 1st through 8th grade students must meet additional criteria which includes screening for language proficiency).

Has your child ever been enrolled in a Dual Language program? Yes No

If yes, please indicate the name of the school, city and state: _________________________________________________________________

Are you interested in your child being enrolled in a Dual Language program? Yes No

PHY: Y N ISBE: Y N KD:

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Federal Requirement (Federal government requires answers to all areas below): Choose only one: No, not Hispanic/Latino Yes, Hispanic/Latino You must also select one or more race below: Race: Native American Asian African American Pacific Islander White Has the child ever attended school in Ilinois? Yes No Date First Enrolled in U.S. School: _____________________ If child was not born in the U.S., please indicate the following attendance in a United States school: Less than 1 year More than 1 year More than 2 years More than 3 years

POR:HLS:

SIB:

NEW STUDENT REGISTRATION – CRYSTAL LAKE ELEMENTARY DISTRICT 47

PARENT/GUARDIAN INFORMATION (complete one of this page per family)

Legal Last Name: Legal First Name:Full Middle Name:

School: _______________ (Office Use Only)

STUDENT LIVES WITH: Mother Father Guardian Other: ___________________________

MOTHER’S MAIDEN NAME (on child’s birth certificate): ________________________________________________ I give my permission to be called and/or texted using automatic dialing equipment by Crystal Lake Elementary District 47 or its agents by checking the phone and/or text boxes by each number below. I understand that I have the right to revoke this consent at any time by notifying Denise Barr, coordinator of community relations, at dcbarr@d47.org, or by following the instructions in the automated phone call or text messages. Parent Legal Name: Relationship to Student: ---------------------------------------------------------------------------------------------------------------------------------------------------------------- Is address same as student? If no, address is: --------------------------------------------------------------------------------------------------------------------------------------------------------------- Email: --------------------------------------------------------------------------------------------------------------------------------------------------------------- Employer: Occupation: --------------------------------------------------------------------------------------------------------------------------------------------------------------- 1. Cell #: OK to: Phone Text 2. Work #: OK to: Phone Text --------------------------------------------------------------------------------------------------------------------------------------------------------------- Check all that apply: Contact Allowed Education Rights Has Custody Lives With Mailings Allowed Enrolling Parent Financial Responsibility

Parent Legal Name: Relationship to Student: ---------------------------------------------------------------------------------------------------------------------------------------------------------------- Is address same as student? If no, address is: --------------------------------------------------------------------------------------------------------------------------------------------------------------- Email: --------------------------------------------------------------------------------------------------------------------------------------------------------------- Employer: Occupation: --------------------------------------------------------------------------------------------------------------------------------------------------------------- 1. Cell #: OK to: Phone Text 2. Work #: OK to: Phone Text --------------------------------------------------------------------------------------------------------------------------------------------------------------- Check all that apply: Contact Allowed Education Rights Has Custody Lives With Mailings Allowed Enrolling Parent Financial Responsibility

In case of emergency, which Parent/Guardian should be contacted first? _____________________________________

_______________________________________________ ________________________ Signature of Parent or Legal Guardian Date

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NEW STUDENT REGISTRATION – CRYSTAL LAKE ELEMENTARY DISTRICT 47

.

LIST OTHER CHILDREN IN YOUR FAMILY UNDER AGE 15 (Please indicate youngest)

Date of Birth: Full Name: Age:

Attends D47 School:

Is Youngest:

Age: Date of Birth:

Age: Date of Birth:

Complete this box only if your answer will help school staff with enrollment and may enable your student to receive additional services: It reflects your child’s current living situation. Check if you or your child are living:

In a shelter With relatives or others due to lack of housing At a train or bus station, or in a car

In a motel/hotel, camping ground or other similar situation due to the lack of alternative, adequate housing

In an abandoned apartment/building

Temporarily housed in a shelter awaiting DCFS permanent foster care placement.

_______________________________________________ ______________________ Signature of Parent or Legal Guardian Date

Form Date 04.21.15

MCKINNEY VENTO HOMELESS EDUCATION ACT ELIGIBILITY: Confidential Information

Attends a dual language program: Address the same as registrant?

Full Name: Attends D47 School

Age: Date of Birth:

Full Name:Attends D47 School:

Is youngest: Attends a dual language program: Address the same as registrant?

Full Name: Attends D47 School Attends a dual language program:

Attends a dual language program:Is youngest:

Address the same as registrant?

Is youngest:Address the same as registrant?

Legal Last Name: ___________________________________ Legal First Name: ________________________ Has your child ever attended the Carl Wehde Center for Early Education? If yes, when did he/she attend: ___________________

EMERGENCY CONTACT(S) if parent/guardian cannot be reached:

Name: Relationship: Address: City: State: Zip Code:

Home Phone: Work Phone: Cell Phone: ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Name: Relationship: Address: City: State: Zip Code:

Home Phone: Work Phone: Cell Phone:

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STUDENT PARTICIPATION FORM Please respond to the items listed below; sign and date. STUDENT ACCEPTABLE USE POLICY – NETWORK:

I am aware that the Student Acceptable Use Policy (AUP) can be located on the district website or in the student handbook. This provides my child electronic access to the District's network. I understand this form will be kept on file for the duration of my child'sattendance at CLSD47. I also understand that if, at any time, I do not wish my child to have network access in District 47, I must submit,in writing, a signed statement to the school office. I understand that my student is expected to comply with the AUP and related materialsand that I may be notified of any changes to the AUP. My ignorance of the AUP and its related materials is not an excuse for a violationor other misconduct. Should I have further questions, I agree to contact the school office.

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LIABILITY PROTECTION:

District 47 policy 7:270, Dispensation of Medication, discusses the self-administration of medication. In accordance with this policy, theliability protection act provides specific liability protections regardless of whether or not a student has a prescription for epinephrine on filewith the school. If a parent/guardian provides his/her student's school with a prescription for epinephrine: The school district must inform theparents or guardians of the pupil, in writing, that the school district and its employees and agents, including a physician providing standingprotocol or prescription for school epinephrine auto-injectors, are to incur no liability, except for willful and wanton conduct, as a result ofany injury arising from the self-administration of medication nor use of an epinephrine auto-injector regardless of whether authorization wasgiven by the pupil's parent/guardian or by the pupil's physician, physician's assistant, or advanced practice registered nurse. 105 ILCS 22-30 (c)The parent/guardian must sign a statement adknowledging this release of liability.If a student does not have a prescription for epinephrine on file with the school and the:...school nurse administers an epinephrine auto injector to a student whom the school nurse in good faith professionally believes is having ananaphylactic reaction, notwithstanding the lack of notice to parent/guardian of the pupil or the absence of the parents or guardians signedstatement acknowledging no liability, except for willful and wanton conduct, the school district and its employees and agents, including aphysician providing standing protocol or prescription for school epinephrine auto-injectors, are to incur no liability, except for willful andwanton conduct, as a result of any injury arising from the use of an epinephrine auto injector regardless of whether authorization was givenby the pupil's parent/guardians or by the pupil's physician, physican's assistant, or advanced practice registered nurse. 105 ILCS 22-30 (c). I am aware of the Liability Protection Policy

================================================================================================== PESTICIDE NOTIFICATION:

Schools are required to provide 96 hours notice to interested staff, students, and parents prior to certain types of pest or plant control applications on school property. Please indicate your interest to be notified two days before the application of pest or plant control materialswhich are subject to notification requirements. I understand that if there is an immediate threat to health or property that requires treatmentbefore notification can be sent out, I will receive notification as soon as practicable.

Yes, please notify me.

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CHILDREN OF U.S. MILITARY PERSONNEL SYSTEM:

Parent/Guardian is a member of the Armed Forces or Full-time National Guard on active duty: Yes No

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Please be advised that the student handbook for the school year you are registering for will be posted on the District websiteunder the Parents tab as of August 1st. By signing this agreement, you acknowledge you have been made aware of the location ofthis document and will refer to it for pertinent information about the District and its procedures.

ACKNOWLEDGEMENT OF DISTRICT 47 STUDENT HANDBOOK LOCATION

Per the above statement, I have been made aware of the location and available date of the District 47 Student Handbook.

Legal Last Name:____________________________________ Legal First Name: __________________ ID: ____________ School: ____________ Date: Parent Signature: ___________________________________________

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CRYSTAL LAKE ELEMENTARY DISTRICT 47 – PARENT INFORMATION

Please review the items listed below; sign and date.

PARENTS OF MIDDLE SCHOOL STUDENTS ONLY:

1. INFORMATION REQUESTED BY CRYSTAL LAKE HIGH SCHOOL DISTRICT 155 PERMISSION. As your child enters into middle school, certain educational and/or demographic information may be requested byCrystal LakeHigh School District 155. Yes, you may provide educational and demographic information to District 155. No, you may not provide educational and/or demographic information to District 155.

Parents/guardians of students who receive a District 47 issued Chromebook must sign the Chromebook Agreementin order to receivethe device; parent/guardian acceptance is required. Use of a Chromebook, like any other use of Districttechnology, is governed bythe District’s Acceptable Use Policy (6:235), which students and their parents/guardians areresponsible for reviewing and understanding.Please indicate your acceptance by checking below. Yes, I agree to the terms of the Chromebook Agreement

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2. CHROMEBOOK USER AGREEMENT:

Student Last Name: Student First Name: ID:

Parent Signature Date:

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CRYSTAL LAKE ELEMENTARY DISTRICT 47 – HEALTH SERVICES SURVEY

Legal Last Name: _________________________________ Legal First Name: ____________________

As you know, good health is vital for an optimal learning experience. To provide the best care possible during school hours the district nursing staff asks that you please complete the following form to help us meet your child’s health related needs. If the school nurse feels the school needs more information about your child’s health, you may be asked for more detailed information regarding your child’s care at school. Please call your school nurse if you have any concerns or issues regarding your child’s health. Thank you.

Medications Yes NoIf yes, please list any medications your child takes at home and the reason the medication was prescribed: Medication: Purpose: Medication: Purpose:

Medication: Purpose: Medication: Purpose:

What medications, if any, will your child need to take at school? PLEASE NOTE: Written permission from the doctor is required for all medications taken at school including Epi-pen and non-

prescription. Inhalers must be accompanied by the prescription label identifying the child and dose of medication. -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Allergies: Yes No What is your child allergic to? (Please include medication, environment, food, seasonal, etc.) Allergy: Reaction? What action is to be taken at school?

Allergy: Reaction? What action is to be taken at school? Does your child carry an Epi-pen? Yes

Call parent only? Yes No

No

Call EMS and parent immediately? Yes No -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Asthma: Yes No During the school year, how often does your child have asthma episodes? Date of last episode: Triggers of asthma episodes: Allergies Infections Weather Exercise Emotional Situations

Other (Please explain: )

Usual symptoms: Wheezing Coughing Difficulty breathing Feeling of chest tightness Other (Please explain):

Treatment for attacks: Rest Liquids Breathing exercises Medications (List): -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Psychological/Psychiatric: Yes No If yes, what diagnosis has your child been given? When was he/she diagnosed? Has your child been hospitalized for this condition, and when? What medication, if any, does your child take for this condition? ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Seizure Disorder: Yes No Type of seizure? Age at diagnosis: Date of last seizure? Average length of seizure? Does your child take anti-seizure medication? Yes No Name of Medication: List special instructions for care after a seizure: If the child is not on medication anymore, when was it stopped? -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Diabetes: Yes No If yes, age of diagnosis? Diet restrictions at school? Yes No If yes, explain: Action to be taken for hypoglycemic reaction: Date of last serious reaction? Type of insulin used? Will student be performing blood sugar monitoring at school? Yes No Insulin Pump? Yes No What are acceptable blood sugar parameters for your child? -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Heart Condition: Yes No If yes, describe the heart problem: Describe any activity restrictions/medications:

Other Health Concerns: ADHD Dental Vision Hearing Orthopedic Other (explain):

Parent Signature:____________________________________ Date:__________________ Student ID:_____________

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SCHOOL MOVING FROM

ADDRESS CITY STATE/ZIP

PHONE FAX

I HEREBY GRANT PERMISSION FOR ALL CONFIDENTIAL, MEDICAL, PSYCHOLOGICAL, EDUCATIONAL

AND/OR INFORMATION MAINTAINED BY THE SCHOOL RELATIVE TO:

Legal Last Name: ______________________________Legal First Name: _____________________ DOB: _________

HAS STUDENT RECEIVED SPECIAL EDUCATION YES NO

Canterbury Elementary School North Elementary School

875 Canterbury 500 Woodstock Street

Crystal Lake, IL 60014

Fax: 815-479-5117 Crystal Lake, IL 60014

Fax: 815-479-5111 Coventry Elementary School Richard F. Bernotas Middle School

820 Darlington Lane 170 N. Oak Street

Crystal Lake, IL 60014

Fax: 815-479-5114Crystal Lake, IL 60014

Fax: 815-479-5116 Glacier Ridge Elementary School South Elementary School

1120 Village Road 601 Golf Road

Crystal Lake, IL 60014

Fax: 815-477-5547 Crystal Lake, IL 60014

Fax: 815-479-5112 Hannah Beardsley Middle School West Elementary School

515 E. Crystal Lake Avenue 100 Briarwood Road

Crystal Lake, IL 60014

Fax: 815-479-5119 Crystal Lake, IL 60014

Fax: 815-479-5115 Husmann Elementary School Woods Creek Elementary School

131 Paddock 1100 W. Alexandra

Crystal Lake, Il 60014

Fax: 815-479-5110 Crystal Lake, IL 60014

Fax: 815-356-2729 Indian Prairie Elementary School Carl Wehde Early Childhood Center

651 W. Village Road 1120 Village Road

Crystal Lake, IL 60014

Fax: 815-479-5118 Crystal Lake, IL 60014

Fax: 815-477-5548 Lundahl Middle School

560 Nash Road

Crystal Lake, IL 60014

Fax: 815-479-5113

School records are available to schools or other agencies upon request with parent or guardian approval.

PARENT/LEGAL GUARDIAN DATE

Updated 05.11.2017

*For students having received special education services, records to be released must include the I.E.P., evaluations

and all information relative to eligibility and placement.

REQUEST AND APPROVAL FOR STUDENT RECORD INFORMATIONSCHOOL DISTRICT 47

300 Commerce Dr., Crystal Lake, IL 60014

Phone (815) 788.5000 Fax (815) 459-0263

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Educational Excellence for All Students is Our Passion and Commitment.

ITEMS REQUIRED AT TIME OF REGISTRATION School Board exhibit 7:60­AP2, E3. IMPORTANT: The School District reserves the right to evaluate the evidence presented, and merely presenting the items listed in this Procedure does not guarantee admission. WARNING: If a student is determined to be a nonresident of the District for whom tuition must be charged, the persons enrolling the student are liable for non­resident tuition from the date the student began attending a District school as a non­resident. A person who knowingly enrolls or attempts to enroll in this School District on a tuition­free basis a student known by that person to be a nonresident of the District is guilty of a Class C misdemeanor, except in very limited situations as defined in State law (105 ILCS 5/10­20.12b(e). A person who knowingly or willfully presents to the School District any false information regarding the residency of a student for the purpose of enabling that student to attend any school in that District without the payment of a nonresident tuition charge is guilty of a Class C misdemeanor (105 ILCS 5/10­20.12b(f).

Proof of Residency ONE of these documents must be provided in order to register your new or returning student

Property Tax Bill in parent/guardian name Click here to find your tax bill Copy of closing documents with property address and signatures of both buyer

and seller. (Example: Settlement Statement or Master Statement) Purchase contract with property address, closing date and signatures of both

buyer and seller. *Contracts within 30 days- Closing documents required after closing date

Current Rental agreement with property address, signatures of both landlord and tenant, and expiration date of the lease term. *New lease required upon expiration If you do not have one of the above, contact the District office to request an

affidavit. *Affidavits are valid for current school year only

Original Certified Birth Certificate

Original birth certificate with impressed seal from the county or state in which your child was born.

Hospital certificates will not be accepted. Note: Students registering for kindergarten must be 5 years of age on or before

September 1 of the school year in which they will attend.

Students transferring FROM AN ILLINOIS SCHOOL

Must provide ONE of the following:

Illinois Student Transfer Form (ISBE 33-78. This should be provided by your child’s prior school.

Illinois Student Health Physical Form, including Immunizations. *NOTE*: Kindergarten students registering PRIOR to the start of the school year must

provide the Illinois Student Physical and Immunizations directly to the school on or before the first day of school.

Students transferring FROM OUT OF STATE

Must provide the following:

Student Health Physical Form that meets the requirements of the State of Illinois Health Physical Form, including Immunizations. Physical must be dated within one year of date of registration.

Other Health Information - Submit to Child’s School

Other Health Forms

Illinois Dental Exam Form—All Kindergarten, 2nd grade, and 6th grade students must provide a dental exam form completed by their dentist by no later than May 15th of the current school year.

Vision Exam Form—Proof of a vision exam performed by an optometrist must be submitted for all Kindergarten students and any student new to Illinois no later than October 15th of the current school year.

C R Y S T A L L A K E E L E M E N T A R Y D I S T R I C T # 4 7 300 Commerce Drive , Crystal Lake, I l l inois 60014 (815) 788 -5000

www.d47.org

/D47schools @crysta llakeSD47