administration center preschool new ...bmlc.psd202.org/documents/1531310683.pdf · preschool new...

Plainfield Community ConsolidatedSchool District 202We prepare learners for the future.

Administration Center15732 Howard StreetPlainfield, IL 60544http://www.psd202.org

(815) 577-4000 – telephone

Preschool New Student Registration ChecklistThe following items are required for Preschool Registration:

1. Completed registration packet

2. Certified birth certificate• Please provide the Official Certified Birth Certificate with raised seal issued by the county/country in

which the student was born. We do not accept any decorative hospital issued certificates.

3. Photo identification (or Passport) of person enrolling the student

4. Any existing legal custody, divorce decree, or guardianship documents• If there are any legal documents pertaining to the custody of the student, you must provide a copy.

5. Physical must be dated on or after August 17, 2016.

6. Current immunizations must be noted on the physical. (see health letter)• Students without a physical examination who have a list of currently required immunizations will not be

allowed to start on the first day of school.

7. Most recent individualized education plan (IEP), if applicable.

8. Payment of Fees• Either payment in full at time of registration or confirmation of payment plan through District 202.

9. 3 Current Proofs of Residency (see next page and enrollment form)

NOTE:•

•

Documents that must be turned in are listed on the next page in the column named Registration Forms to be Turned In.

Documents that are for your information or are optional dependent on living situations are listed on the next page in the column named Registration Paperwork for Reference.

Plainfield Community Consolidated School District 202Residency Requirements Checklist

Proofs must be in the Parent/Guardian name with an address that is within School District 202 Boundaries.3 proofs are required, with at least one document from category A and one document from category B.

Category A – Current ResidencyRecent real estate tax billLease (signed showing date of occupancy with landlord’s name and phone number)Settlement statement (signed and within 30 days)Truth in lending statement (signed and within 30 days)Warranty deed (within 30 days)Mortgage statement / Payment book (within 30 days)Bill of Sale (within 30 days)Military housing letterResidency affidavit (Completed and Notarized)

Category B – Current ResidencyMUST BE ISSUED WITHIN THE LAST

3 MONTHS

Auto registrationHomeowners or renters insuranceDriver’s license or state identificationPhoto identification from foreign consulate

MUST BE ISSUED WITHIN THE LAST30 DAYS

Cable billUtility bill – gas, electric, waterLetter from government agencyBank statement

Registration Forms to be Turned InPage(s)

Enrollment formEarly Learning RequirementsStudent registration contact informationMilitary personnel questionnaireRace and ethnicity formHome language surveyAcceptable use of technology formHealth history formPhysical form with current immunizations

Registration Paperwork for ReferencePage(s)

School supply listDistrict 202 school calendarHealth letterRace and ethnicity information letterOptional – Transportation Sitter FormOptional – Medication AuthorizationOptional – Guardianship AffidavitOptional – Residency Affidavit

Fee statement and information will be sent in summer

** Note: If you do not own or rent the home in which you are residing, please obtain the student residency affidavit along with the proofs listed above. **

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(815) 577-4000 – telephone

Enrollment FormStudent Residency Requirements

Directions: Carefully read and complete each of the following sections. You are required to provide both proof of residency documents and custodial information.

Residency of Person with Legal Custody of the StudentAs initial proof of residency, the person with legal custody of the student and with whom the student lives within School District 202 boundaries must provide at least one document from Category A and at least one documents from Category B.(A total of three documents is required).

In order to enroll without established residency, proof of future residency as described in Category C along with a $350.00 non-refundable fee per family is required.

Category A and B documents must be submitted when actual occupancy occurs. If the registering adult claims the student is homeless, Category D applies.

NOTE: If you do not own or rent the home in which you are residing, you are required to submit the residency affidavit along with the proofs of residency and may require additional paperwork. Proof of residency must be provided every year if the student is enrolled based upon a third party or lease.

Identifying Information: (To be completed by the person with legal custody of the student. Please print.)

Your namePhone number(s) Home: Cell: Work:Current address Address:

City:State: Zip Code:

Subdivision:Future Address(if under contract)

Address:City:

State: Zip Code:Subdivision:

Student’s name Grade Entering Re-enrollment? Yes NoRelation to student Mother Father Step-Mother Step-Father Aunt Uncle Guardian Other:School

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Plainfield Community Consolidated School District 202Enrollment Form - Residency Requirements Checklist

To Prove CURRENT Residency in School District 202:Proofs must be in the Parent/Guardian name with an address that is within School District 202 Boundaries.3 proofs are required, with at least one document from category A and one document from category B.

Category A – Current ResidencyRecent real estate tax billLease (signed showing date of occupancy with landlord’s name and phone number)Settlement statement (signed and within 30 days)Truth in lending statement (signed and within 30 days)Warranty deed (within 30 days)Mortgage statement / Payment book (within 30 days)Bill of Sale (within 30 days)Military housing letterResidency affidavit (Completed and Notarized)

Category B – Current ResidencyMUST BE ISSUED WITHIN THE LAST

3 MONTHS

Auto registrationHomeowners or renters insuranceDriver’s license or state identificationPhoto identification from foreign consulate



To prove FUTURE residency in School District 202: One proof is required as described below

Category C - All non-residents must move into the Plainfield School District boundaries within 120 calendar days, provide proof of residency within 2 weeks after moving into the District and pay a $350.00 non-refundable fee per

family.A fully executed purchase agreement stating an approximate closing dateA fully executed sales contract, showing no unsatisfied contingenciesA fully signed lease with occupancy beginning the 1st day of student attendance

To enroll student as "Homeless" in School District 202: Mark below.Category D - Homeless

None of the documents in Categories A, B, or C above are applicable because the student is homeless and eligible for enrollment under the Illinois Education for Homeless Children Act. Please notify your student's school to speak with the Homeless Liaison.

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Enrollment Form - Proof of Custody

To Prove CUSTODY in School District 202: You must check one of the following descriptions in either, Grounds for Legal Custody OR Exceptions. Additional paperwork may be required.

Grounds for Legal CustodyCheck one of the following as applicable.If none is applicable, you must check one of the "Exceptions" noted below.

Custody is exercised by a natural or an adoptive parent with whom the student resides.Custody has been granted by court order to a person with whom the student resides for reasons other than to have access to the educational programs of this District. (Attach copy of court order)Custody is exercised under a court approved short-term guardianship. (Attach copy of court order)Custody is exercised by a caretaker adult relative who is receiving aid under the Illinois Public Aid Code for the student who resides with that caretaker for the purposes other than to have access to the educational programs of this District. (Attach copy of Public Aid documents)Custody is exercised by an adult who demonstrates that, in fact, he or she has assumed and exercises legal responsibility for the student and provides the student with a regular fixed nighttime dwelling for purposes other than to have access to the educational programs of this District. (Attach completed & notarized guardianship affidavit - MUST be approved by school administration)

Additional Informationor Explanation:

ExceptionsIf none of the above "Grounds for Legal Custody" apply, you must check one of the "Exceptions" noted below.

The student is homeless.The student is a foreign exchange student.The student has been placed with a foster parent or child care facility by the Department of Children and Family Services outside this District, but DCFS has determined it to be in the best interests of the student to maintain attendance in this District! (Attach copy of DCFS determination)The student is at least 18 years old and lives in this District on a full and indefinite length of time basis.The student is under 18, but has been emancipated by court order or marriage and lives in this District on a full and indefinite length of time basis. (Attach copy of court order or marriage license)

Warnings and AffirmationGenerally, Illinois law permits only students who are residents of School District 202 to enroll and attend on a tuition-free basis. Under the law, the residence of a student is deemed to be the residence of the person who has legal custody of the student. "If a pupil is determined to be a nonresident of the District for whom tuition is required to be charged pursuant to this section, the School Board shall refuse to permit the pupil to continue attending the schools of the District unless the required tuition is paid for the pupil." "A person who knowingly or willfully presents to any School District any false information regarding the residency of a pupil for the purpose of enabling that pupil to attend any school in that District without the payment of a non-resident tuition charge shall be guilty of a Class C Misdemeanor." (l05 ILCS 5/10-20.12b) 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. The School 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 School District. I affirm that I am a resident of this District and that the information presented in this Affidavit or in connection with any investigation of my residency or the residency of the student is true, complete, and accurate.

I also give approval for the release of information to District 202 to obtain any documents or information to verify my residency. This release remains valid with no exception.

Signature of Person with Legal Custody of the Student Date

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(815) 577-4000 – telephone

State of IL Requirements for Early LearningThe following questionnaire is required by the State of Illinois and all data collected will remain confidential.

Student Name: Grade: School:

1: Did the child ever receive Early Head Start services?Prior to attending Bonnie McBeth, the child received Early Head Start services which may include home-based services, center-based services, or both.

Yes No

2: Did the child ever participate in a birth to age 3 years Prevention Initiative program?Prior to attending Bonnie McBeth, the child participated in a birth to age 3 years Prevention Initiative program for at-risk children and their families. Funding for this program comes from the Early Childhood Block Grant.

Yes No

3: Did the child ever receive Early Intervention services?Prior to attending Bonnie McBeth, the child received Early Intervention services designed for families who have infants and toddlers, birth to three, with diagnosed disabilities, developmental delays, or substantial risk of significant delays. Funding for this program comes from the Illinois Department of Human Services (Infants and Toddlers with disabilities) (DHS).

Yes No

4: Was child previously enrolled in an Early Childhood program?The child has a previous enrollment in an early childhood program.

Yes No

5: Was child previously enrolled in Child Care?Prior to attending Bonnie McBeth, the child was enrolled in Child Care.

Yes No

6: Was there any Child Welfare Involvement within the Past Year?The child or their family has received services from the Department of Children and Family Services (DCFS), including foster care, intact family services or the parent has been a ward of the state.

Yes No

7: Does the family have an open intact family services case?The family has been assigned a caseworker by DCFS and is currently receiving or in the past year has received family services.

Yes No

8: Is the child's parent in a Youth in Care program?Either parent of the child is currently or at any point in the past year has been a ward of the state.

Yes No

9: Is the family receiving TANF?The Temporary Assistance for Needy Families (TANF) program provides temporary financial assistance for pregnant women and families with one or more dependent children.

Yes No

10: Is the family receiving WIC?WIC provides Federal grants to States for supplemental foods, health care referrals, and nutrition education for low-income pregnant, breastfeeding, and non-breastfeeding postpartum women, and to infants and children up to age five who are found to be at nutritional risk.

Yes No

11: Is the family receiving SNAP?The Supplemental Nutrition Assistance Program (SNAP) (formerly Food Stamps) helps low-income people and families buy the food they need for good health. Benefits are provided on the Illinois Link Card - an electronic card that is accepted at most grocery stores. The program is managed by the Food and Nutrition Service (FNS) of the United States Department of Agriculture. The Department of Human Services administers the program in Illinois.

Yes No

12: Is the family receiving housing subsidy?Subsidized housing or social housing is government supported accommodation for people with low to moderate incomes. Forms of subsidies include direct housing subsidies, non-profit housing, public housing, rent supplements and some forms of co-operative and private sector housing.

Yes No

13: Has the child been in a Youth in Care setting?The child is currently in or at any point during the past year has lived in a foster care setting.

Yes No

14: Where does the family's household income criteria fall?The child is from a family whose income is less than 50%, 100%, 200% or 400% of the poverty guidelines updated periodically in the Federal Register by the U.S. Department of Health and Human Services (HHS) under the authority of 42 U.S.C. 9902(2).

At or below 50% FPLBetween 50% and 100% FPLBetween 100% and 200% FPL

Between 200% and 400% FPLMore than 400% FPLN/A (Homeless or Youth in Care)

FPL = Federal Poverty Level. See chart below before checking a box.

Please contact the Bonnie McBeth office staff with updates should any of this information change.

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2017 Poverty Level Guidelines

Annual Income Guide LineHousehold/Family Size 50% of FPL 100% of FPL 200% of FPL 400% FPL More than 400% FPL

1 $6,030 $12,060 $24,120 $48,240 $48,241 or higher2 $8,120 $16,240 $32,480 $64,960 $64,961 or higher3 $10,210 $20,420 $40,840 $81,680 $81,681 or higher4 $12,300 $24,600 $49,200 $98,400 $98,401 or higher5 $14,390 $28,780 $57,560 $115,120 $115,121 or higher6 $16,480 $32,960 $65,920 $131,840 $131,841 or higher7 $18,570 $37,140 $74,280 $148,560 $148,561 or higher8 $20,660 $41,320 $82,640 $165,280 $165,281 or higher9 $22,750 $45,500 $91,000 $182,000 $182,001 or higher10 $24,840 $49,680 $99,360 $198,720 $198,721 or higher11 $26,930 $53,860 $107,720 $215,440 $215,441 or higher12 $29,020 $58,040 $116,080 $232,160 $232,161 or higher13 $31,110 $62,220 $124,440 $248,880 $248,881 or higher14 $33,200 $66,400 $132,800 $265,600 $265,601 or higher15 $35,290 $70,580 $141,160 $282,320 $282,321 or higher

^ Add $4,180.00 for each ^ additional family member.

Monthly Income Guide LineHousehold/Family Size 50% of FPL 100% of FPL 200% of FPL 400% FPL More than 400% FPL

1 $503 $1,005 $2,010 $4,020 $4,021 or higher2 $677 $1,353 $2,707 $5,413 $5,414 or higher3 $851 $1,702 $3,403 $6,807 $6,808 or higher4 $1,025 $2,050 $4,100 $8,200 $8,201 or higher5 $1,199 $2,398 $4,797 $9,593 $9,594 or higher6 $1,373 $2,747 $5,493 $10,987 $10,988 or higher7 $1,547 $3,095 $6,190 $12,380 $12,381 or higher8 $1,722 $3,443 $6,887 $13,773 $13,774 or higher9 $1,896 $3,792 $7,583 $15,167 $15,168 or higher10 $2,070 $4,140 $8,280 $16,560 $16,561 or higher11 $2,244 $4,488 $8,977 $17,953 $17,954 or higher12 $2,418 $4,837 $9,673 $19,347 $19,348 or higher13 $2,592 $5,185 $10,370 $20,740 $20,741 or higher14 $2,767 $5,533 $11,067 $22,133 $22,134 or higher15 $2,941 $5,882 $11,763 $23,526 $23,527 or higher

^ Add $348.33 for each ^ additional family member.

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(815) 577-4000 – telephone

Student Registration - Contact InformationPlease print clearlyStudent Information

School: Student ID#: (for office use only)

Student's Legal Name: (as listed on birth certificate-First, Middle, Last)

First: Middle: Last:

Name Student Goes By:

Date of Birth: Gender: Male Female Grade:

Birthplace: City: State/Country:

Street Address:

City: State: Zip Code:

Subdivision: Home Phone #:

Student Resides With (at address above): Contact #1Relationship to Student:

Mother Father Step-Mother Step-FatherAunt Uncle Guardian Other:

Legal Custody: Yes No

Contact's Legal Name: (Legal First, Middle Initial, Last)


Home Phone Number: Cell Phone Number:

Employer Name:

Work Phone Number: Education Level: High School & Up

Less than High SchoolUnknownE-mail Address:

Preferred Language for School Written & Electronic Communication: English Spanish Other:

Student Resides With (at address above): Contact #2Relationship to Student:






Employer Name:




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Other Custodial Parent – Student Does Not Reside WithRelationship to Student:





Street Address:



Employer Name:




Emergency Contact #1Contact's Legal Name: (Legal First, Middle Initial, Last)


Relationship to Student:

Aunt Uncle Neighbor Friend Childcare ProviderOther:

Street Address:







Street Address:







Street Address:



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Medical InformationWears Glasses: Yes No Wears Contact Lenses: Yes NoMedical Information: Please list any medical conditions we need to know about.

Previous Schooling InformationPrevious School Student Attended:

Did your student receive special services and/or programs at their previous school?

SpeechELL - English Language LearnerESL - English as a Second LanguageIEP - Individualized Education ProgramSection 504 PlanGifted/AcceleratedTitle IRTI - Reading InterventionRTI - Math InterventionSocial Worker/CounselorDirect ServicesFree / Reduced Waiver

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

Other:Has the student ever attended Plainfield Schools in the past? If so, please provide school name.

Yes NoSchool:

Has your student previously attended USA schools? Yes No

Siblings that are currently attending Plainfield School District 202Student Name Current School Grade Date of Birth

It is imperative that all items on this registration form are complete.As parent/guardian of the above named student, I affirm that I have completed this form in its entirety and to the best of my knowledge.**NOTE: All information must be complete for a contact or emergency contact to be valid. **

Print Name:

Signature: Date:RECORDED MESSAGE DISCLAIMER FOR ALL REGISTRATION PACKETSPlease Note: District 202 uses a message system incorporating recorded telephone calls, emails and text messages to communicate a wide range of emergency and non-emergency information with families.

This system operates through traditional land lines (telephone messages), computers (emails) and personal smart phones (telephone messages, text messages, apps, etc.).

District 202 will use all contact information provided on this form for automated telephone and text messages. You may contact your school directly to modify how you receive automated telephone and text messages, or to 'opt out' of such communications altogether.

Any modifications to how you receive automated telephone and text messages will not affect your school’s ability to reach you through other communications, and will not affect your school’s ability to use automated telephone and text messages for emergencies.

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(815) 577-4000 – telephone

Military PersonnelIllinois State Board of Education

Children of U.S. Military Personnel System

Plainfield Community Consolidated School District 202 is required by the Illinois School Board of Education to provide parents/guardians the opportunity to respond to the Children of U.S. Military Personnel data

"At the time of annual enrollment or at any time during the school year, a school district or a recognized non-public school, except for sectarian non-public schools, serving any of grades kindergarten through 12 shall provide, either on its standard enrollment form or on a separate form, the opportunity for the individual enrolling the student to voluntarily state whether the student has a parent or guardian who is a member of a branch of the armed forces of the United States and who is either deployed to active duty or expects to be deployed to active duty during the school year. Each school district and recognized non-public school shall report this

For the 2017-2018 School Year Date:

Student that are currently attending Plainfield School District 202Student Name Current School Grade Date of Birth

Parent/Guardian is a member of a branch of the United States armed forces: Yes No

If yes, are you currently deployed to active duty or expect to be deployed to active duty during the 2017-2018 school year: Yes No

Parent/Guardian signature:

Parent/Guardian name:Please print clearly

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(815) 577-4000 – telephone

Dear Parent or Guardian,

Enclosed is the form that parents or guardians need to complete to identify race and ethnicity for their children.

Please complete one form per child, and be sure to answer both parts of the two-part question. Remember

that school district staff is required to provide any missing information by observer identification. Return the

completed form to your child’s school with registration.

In fall 2007, the U.S. Department of Education issued new guidance on the collection and reporting of race and

ethnicity data for public school students and staff. The guidance implements new federal race and ethnicity

categories that were developed to obtain a more accurate picture of the nation’s diversity. The new data

collection process requires respondents to answer a two-part question, indicating ethnicity and then one or more

of five races. In the past, individuals were allowed to choose only one race or ethnicity category.

The Illinois State Board of Education (ISBE) will use the new categories starting with data to be reported for

the 2010-11 school year. This requires school districts to re-identify race and ethnicity for all students - and the

identification is to be done by parents or guardians. If a student’s parents or guardians decline to indicate race

and/or ethnicity, observer identification by school district staff is required.

The new race and ethnicity data will be used in the same manner as previously collected data, e.g., in reporting

and analyzing test results by race and ethnicity. The information will not be used to check immigration status,

and the confidentiality of individual student information will be protected.

Thank you for your cooperation in providing the needed data. Please direct any questions you may have to the

administration at your child’s school.

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(815) 577-4000 – telephone

Illinois State Board of EducationNew U.S. Department of Education Race and Ethnicity Data Standards

Note: Every student’s parents or guardians must respond to both questions (Part A and Part B). If the parents or guardians decline to respond to either question (Part A or Part B), school district staff are required to provide the missing information by observer identification.

Student name: ID #

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 race and Part B asks about the student’s ethnicity.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? Choose only one.(A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)

No, not Hispanic/LatinoYes, Hispanic/Latino

The question above is about ethnicity, not race. No matter which answer you selected, continue and 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: Date:

Note: Data collected on this form must be maintained by the school district for three years. However, when there is litigation, a claim, an audit, or another action involving this record, the original responses must be retained until the

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(815) 577-4000 – telephone

Home Language Survey - Form A

The State of Illinois School Code requires that each school district shall administer a Home Language Survey to each student entering the school district for the first time. The information is used to identify the need for English language support services for your child.

Student's Name:Last First Middle

Date of Birth: Country of Birth:

School: Grade:

1. Is a language other than English spoken in your home? Yes No

If yes, which language?

2. Does your son/daughter speak a language other than English? Yes No

If yes, which language?

If the answer to question 1 or 2 is YES, the school will assess your child’s English language proficiency. As required by Illinois State law, the school will use the pre-IPT (PK only), WIDA Model, or W-APT test to measure your child’s listening, speaking, reading, and writing skills.

3. Has your son/daughter received English as a Second Language (ESL) support services in any previous school district in the USA?

Yes No

If ‘yes’, please provide state and school district

State

School District

SignatureParent or legal guardian Date

Distribution: Original/Student cumulative file Revised: 05/04/2015 FORM #247

OFFICIAL USE ONLYDistrict Enrollment Date:

ELL Program Entry Date:

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(815) 577-4000 – telephone

Authorization Form:ACCEPTABLE USE OF TECHNOLOGY POLICY (AUP)

AUTHORIZATION FORM**** The following section must be completed by all employees, students, and users of District electronic resources ****

By signing below, I acknowledge that I have received, read, and understand the Acceptable Use of Technology Policy (AUP), and any implementing administrative procedures, handbooks, and guidelines. I agree to all terms of the AUP and related materials. I understand that it is my responsibility to become acquainted with the AUP and related materials, and to keep up-to-date on any changes that may be implemented from time to time. I understand that I am expected to comply by the AUP and related materials, that I may not be notified immediately by the District of changes to the AUP and related materials, and that my ignorance of the AUP and related materials is not an excuse for a violation or other misconduct. I understand that I may be disciplined (up to and including suspension and expulsion, for students, and dismissal, for employees) and/or subject to other legal action for violations of the AUP and related materials.

User’s Full Name (please print) Date of Birth

User’s Position (for Employees), Grade (for Students), or Relationship with District (for All Other Users) (please print)

User’s Signature Date

**** The following section must be completed by each student user’s parent/guardian ****As the parent/guardian of the student signing above, I acknowledge that I have received, read, and understand the Acceptable Use of Technology Policy (AUP), and any implementing administrative procedures, handbooks, and guidelines. I agree to all terms of the AUP and related materials for myself and for my student. I understand that it is my responsibility to make sure my student and I are acquainted with the AUP and related materials and keep up-to- date on any changes that may be implemented from time to time. I understand that my student is expected to comply with the AUP and related materials, that my student and I may not be notified immediately by the District of changes to the AUP and related materials, and that my or my student’s ignorance of the AUP and related materials is not an excuse for a violation or other misconduct. I understand that my student may be disciplined (up to and including suspension and expulsion) and/or subject to other legal action for violations of the AUP and related materials.

Parent/Guardian’s Full Name Date

Parent/Guardian’s Signature

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(815) 577-4000 – telephone

Student Health History School Year 2017-2018Student Name: Grade: School:

Sex: Male Female Birth Date: Phone Number:

Doctor’s Name:

(if you indicate YES for any category, please explain)

# Concern Yes or No Explanation & Comments

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

Allergies

*Uses EpiPen

Asthma

*Uses Inhaler

*Uses Inhaler at School

Blood Disorders

Daily Medications

*Names of Medication(s)

School Medications REQUIREMedical Authorization Form

Diabetes

Ear / Hearing Problems

Glasses / Contacts

Eye / Vision Problems

Heart Problems

Hospitalizations

Mental Health Concerns

Neurological Problems

Physical Restrictions

Seizures

Serious Injuries

Surgery

Other

At home

At school

Last eye exam:

Age:

Age:

Age:

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Rarely Once daily More than once daily For Sports

I release this information to be shared with appropriate school and emergency personnel for health and educational purposes.

Parent / Guardian Signature Date

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State of IllinoisCertificate of Child Health Examination

Student's Name

Last First Middle

Birth Date

Month/Day/Year

Sex Race/Ethnicity School/Grade Level/ID#

Address Street City ZIP Code Parent/Guardian Telephone# Home WorkIMMUNIZATIONS: To be completed by health care provider. The mo/da/yr for every dose administered is required. If a specific vaccine is medically contraindicated, a separate written statement must be attached by the health care provider responsible for completing the health examination explaining the medical reason for the contraindication.REQUIREDVaccine / Dose

DTP or DTaP

Tdap; Td orPediatric DT

Polio

Hib

Pneumococcal Conjugate

Hepatitis B

MMR

Varicella

Meningococcal conjugate (MCV4)

(Check specific type)

(Check specific type)

Haemophilus influenza type b

Measles, Mumps, RubellaComments:

(Chickenpox)

RECOMMENDED, BUT NOT REQUIRED Vaccine / Dose

Hepatitis A

HPV

Influenza

Other: Specify any immunizations administered and dates

DOSE 1Month Day Year

Tdap Td DT

IPV OPV


Tdap Td DT

IPV OPV


Tdap Td DT

IPV OPV


Tdap Td DT

IPV OPV


Tdap Td DT

IPV OPV


Tdap Td DT

IPV OPV

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 Title DateALTERNATIVE PROOF OF IMMUNITY1. Clinical diagnosis (measles, mumps, hepatitis B) is allowed when verified by physician and supported with lab confirmation. Attach copy of lab result.

*MEASLES (Rubeola) **MUMPS HEPATITIS B VARICELLAMonth Day Year Month Day Year Month Day Year Month Day Year

2. History of varicella (chickenpox) disease is acceptable if verified by health care provider, school health professional or health official.Person signing below verifies 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 Title

3. Laboratory Evidence of Immunity (check one) Measles * Mumps ** Rubella Varicella Attach copy of lab result.*All measles cases diagnosed on or after July 1, 2002, must be confirmed by laboratory evidence.

**All mumps cases diagnosed on or after July 1, 2013, must be confirmed by laboratory evidence.

Completion of Alternatives 1 or 3 MUST be accompanied by Labs & Physician Signature:Physician Statements of Immunity MUST be submitted to IDPH for review.

Certificates of Religious Exemption to Immunizations or Physician Medical Statements of Medical Contraindication Are Reviewed and Maintained by the School Authority.

11/2015 (COMPLETE BOTH PAGES) Printed by Authority of the State of Illinois

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Last First Middle Birth Date Month/Day/Year Sex School Grade Level/ ID

HEALTH HISTORY TO BE COMPLETED AND SIGNED BY PARENT/GUARDIAN AND VERIFIED BY HEALTH CARE PROVIDERALLERGIES(Food, drug, insect, other)

YesNo

List:

Diagnosis of asthma? Yes NoChild wakes during night coughing? Yes No

Birth defects? Yes NoDevelopmental delay? Yes No

Blood disorders? Hemophilia,Sickle Cell, Other? Explain.

Yes No

Diabetes? Yes No

Head injury/Concussion/Passed out? Yes No

Seizures? What are they like? Yes No

Heart problem/Shortness of breath? Yes No

Heart murmur/High blood pressure? Yes No

Dizziness or chest pain with exercise? Yes No

Eye/Vision problems? No Glasses Contacts Last exam by eye doctorOther concerns? (crossed eye, drooping lids, squinting, difficulty reading)

Ear/Hearing problems? Yes No

Bone/Joint problem/injury/scoliosis? Yes No

MEDICATION(List all prescribed or taken on a regular basis.)

YesNo

List:

Loss of function of one of paired organs? (eye/ear/kidney/testicle)

Yes No

Hospitalizations?When? What for?

Yes No

Surgery? (List all.)When? What for?

Yes No

Serious injury or illness? Yes No

TB skin test positive (past/present)? * Yes No *If yes, refer to local health department.

TB disease (past or present)? * Yes No

Tobacco use (type, frequency)? Yes No

Alcohol/Drug use? Yes No

Family history of sudden death before age 50? (Cause?)

Yes No

Dental Braces Bridge Plate Other

Information may be shared with appropriate personnel for health and educational purposes.Parent/GuardianSignature Date

PHYSICAL EXAMINATION REQUIREMENTS Entire section below to be completed by MD/DO/APN/PAHEAD CIRCUMFERENCE if < 2-3 years old HEIGHT WEIGHT BMI B/PDIABETES SCREENING (NOT REQUIRED FOR DAY CARE) BMI>85%age/sex Yes No And any two of the following: Family History Yes NoEthnic 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 ResultTB 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 in high

prevalence countries or those exposed to adults in high-risk categories. See CDC guidelines. http://www.cdc.gov/tb/publications/factsheets/testing/TB_testing.htm.No test needed Test performed

Skin Test: Date Read / / Result: Positive Negative mmBlood Test: Date Reported / / Result: Positive Negative Value

LAB TESTS (Recommended) Date Results Date ResultsHemoglobin or Hematocrit

Urinalysis

Sickle Cell (when indicated)

Developmental Screening Tool

SYSTEM REVIEW Normal Comments/Follow-up/Needs

SkinEars Screening Result:Eyes Screening Result:NoseThroatMouth/DentalCardiovascular/HTNRespiratory Diagnosis of Asthma

Normal Comments/Follow-up/Needs

EndocrineGastrointestinalGenito-Urinary LMP

NeurologicalMusculoskeletalSpinal ExamNutritional statusMental Health

Currently Prescribed Asthma Medication:Quick-relief medication (e.g. Short Acting Beta Agonist)Controller medication (e.g. inhaled corticosteroid)

Other

NEEDS/MODIFICATIONS required in the school setting DIETARY Needs/Restriction

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 (If No or Modified please attach explanation.)PHYSICAL EDUCATION Yes No Modified INTERSCHOLASTIC SPORTS Yes No Modified

Print Name (MD,DO, APN, PA) Signature Date

Address Phone(COMPLETE BOTH PAGES)

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(815) 577-4000 – telephone

Bonnie McBeth Learning CenterPreschool and Early Childhood Supply List

for School year 2017-2018Quantity Item

1 Backpack with Zipper (approximately 10" x 14") without wheels

1 Folder (with 2 pockets to keep in backpack)

2 boxes Facial tissue

1 Wide tip dry erase marker (low odor) – no yellow

4 Elmer’s glue sticks

1 Elmer’s glue bottle (4 oz.)

1 10-count package of wide tip WASHABLE markers (Only students whose last name starts with A-R)

1 box 24 thin crayons (Only students whose last name starts with S-Z)

1 Change of clothing in plastic bay to stay at school (socks, underwear, shirt, pants)Please label all clothing with child’s name and replace as the seasons change

** Supplies "run out" during the school year. Please check with your child periodically to see if any need replacing **

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(815) 577-4000 – telephone

Preschool Health RequirementsDear Preschool Parents/Guardians,

The District 202 nursing staff welcomes you and your child as he/she begins preschool.

Incoming preschool students must have the following health examinations on file at your child’s school according to the Illinois Department of Public Health and PSD 202 Board of Education policy.

⦁ A physical examination that has taken place within one year prior to school entry. Students without a physical examination and list of current immunizations will not be allowed to start on the first day of school per District 202 Board of Education policy. The examination must be signed by the medical provider and be recorded on the Certificate of Child Health Examination form (11-15). The health history section of the examination form must be completed and signed by the parent. All students age 6 and under must have the lead screening section completed by the medical provider. In addition, the diabetes screening section must also be completed.

⦁ The immunizations required for preschool entry are:⦁ Four or more doses of DTP/DTaP (diphtheria, tetanus, pertussis), with 3 doses given by 1 year of

age and one additional dose by the 2nd birthday. All doses must be at least 4 weeks apart. ⦁ Three or more doses of polio, with 2 doses by 1 year of age and one additional dose by the 2nd

birthday. All doses received must be no less than 4 weeks apart. ⦁ One dose each of measles, mumps and rubella (usually given as MMR) given on or after the 1st

birthday and prior to 24 months of age. ⦁ At least one dose of Hib (haemophilus influenza type b) given after 15 months of age⦁ Three doses of hepatitis B received at the appropriate intervals with the 3rd dose received on or

after 6 months of age.⦁ One dose of varicella (chicken pox) received on or after the 1st birthday⦁ At least one dose of PCV (pneumococcal conjugate vaccine) given after 24 months of age.

Please make your doctor’s appointments early. Doctor’s offices are very busy during the summer months with back-to-school appointments and it will get very difficult to get an appointment as the first day of school approaches. Please make copies of all papers submitted and keep them for your records.

Child Health Examination forms and medication forms may be found at www.psd202.org > Departments and Programs > Health Services. If you have any questions, or your child has any specific health care needs such as diabetes, allergies, asthma, seizure disorder or medication that needs to be taken at school, please contact Teresa Rogers, RN, the building nurse for Bonnie McBeth Early Learning Center.

Sincerely,

Jill Accardo, BSN, MBA, RN, PEL-CSN, NCSN, Nursing CoordinatorTeresa Rogers, RN, Building Nurse, Phone: 815-577-4155, Email: TRogers@psd202org

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(815) 577-4000 – telephone

TRANSPORTATION OFFICE14812 S. Eastern Avenue, Plainfield, IL 60544

PHONE: (815) 436-7800 FAX: (815) 439-4830

TRANSPORTATION POLICY FOR STOP LOCATION OTHER THAN STOP ASSIGNED TO HOME ADDRESS

During the school year, students may be transported to / from one stop address other than their home bus stop; however, the stop must be for every day of the week. The stop address must also be within the student's school attendance boundaries.

The four possible choices for bus transportation are:1. Pick up at home; drop off at home.2. Pick up at home; drop off at sitter.3. Pick up at sitter; drop off at sitter.4. Pick up at sitter; drop off at home.

Students who are transported to / from a bus stop other than their assigned stop must have a parent / guardian signed transportation request form on file at the District’s Transportation Department. A copy of that form is on the next page. Additional copies are available in each school’s main office or at the District Office.

Requests received by the District Transportation Office will become effective after (3) threeschool days.

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Transportation Sitter FormStudents who are regularly transported to or from a bus stop other than the one assigned for their home address must have a signed, current request on file at the District’s Transportation Office. Sitter forms must be re-submitted annually. Requests are granted based on current seats available, time schedules, and must be within the attendance boundaries of the school your child is attending. Information is also requested if District 202 does not transport the student due to day care center/sitter or parent transportation. Transportation must be to the same address 5 days per week. The address provided for morning transportation may be different from the afternoon address.

Please return this form to: TRANSPORTATION OFFICE14812 S. Eastern AvenuePlainfield, IL 60544

Or fax it as soon as possible to: (815) 439-4830

The District Transportation Office Requires a three (3) day notice (working days) to implement busing changes during the school year and a 2 week notice prior to start up of a new school year.

If you have any questions, please call Transportation at 815-436-7800

REQUEST TO TRANSPORT STUDENT TO/FROM DIFFERENT BUS STOP

STUDENT’S NAME:(Last Name) (First Name)

SCHOOL: GRADE:

HOME ADDRESS: CITY: ZIP:

HOME PHONE NUMBER: HOME SUBDIVISION:

WORK PHONE NUMBER(S) OF PARENT/GUARDIAN(S):

DAD: MOM:

SITTER’S NAME:

SITTER’S ADDRESS: CITY: ZIP:

SITTER’S PHONE NUMBER: SITTER’S SUBDIVISION:

Select the time of day to be bused to and/or from the sitter: To school only From school only Both ways

DATE FOR BUSING TO START AT SITTER:

ADDITIONALCOMMENTS:

PARENT / GUARDIAN NAME PRINTED:

SIGNATURE: DATE:

Adult providing childcare is required to sign the statement belowI acknowledge the above named student is in my care as indicated above requiring transportation from the bus stop associated to my address. I understand I am responsible they arrive to and/or from the bus stop safely, and am responsible for their behavior at the bus stop. SITTER'S SIGNATURE: DATE:

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(815) 577-4000 – telephone

Medication Authorization Form1. Medications, which include both OVER-THE-COUNTER and PRESCRIPTION, to be taken during the school day will only be administered

after the parent/guardian and physician completes a Plainfield School District “Medication Authorization Form” which is available from the building nurse or the district website. A new form must be filled out for each new school year or whenever the medication or its dosage is changed, and when asked to do so by the school nurse.

2. The first dosage of medication should not be given at school in case the student suffers an allergic or other adverse reaction.

3. Medication will be brought to school by a parent/guardian and must be in its original container or prescription bottle appropriately labeled with the student’s name, name of medication, the dosage and all pertinent instructions. If it is absolutely impossible for the parent/guardian to bring in the medication, we ask that students, upon their immediate arrival to school, turn the medication into the office in a sealed envelope with the parent’s signature across the seal with a count of the number of pills that are contained in the envelope. If the parent/guardian does not pick up the medication at the end of the school year, the medication will be disposed of in the presence of a witness and documented.

4. Medication will be stored in school in a safe place. Students must come to the nurse’s office for their medication. The school will strive to assist students in grades K-5 to remember to come to the office to take his/her medication.

5. Except where a student is authorized to self-administer insulin, an epinephrine auto-injector or asthma medication; students are prohibited from keeping any kind of medication in their possession while at school. Students must have the Hold Harmless and Indemnity form signed by their parent and physician to keep their inhaler or epinephrine auto-injector with them in school.

6. A certified school nurse or registered professional nurse, if available, shall administer the medication. If a nurse is unavailable, a building administrator or other staff member who volunteers may either: 1) Supervise the self-administration of the medication; or 2) administer the medication himself/herself.

7. Medications will generally not be administered to students during field trips or other school-sponsored activities located away from the customary site of storage. In these situations, medication will only be administered to a student if absolutely necessary for the critical health and well-being of the student as documented in a student’s individualized health care plan. Medication in these situations must be sent to school by a parent/guardian, in an original pharmaceutical container labeled with the student’s name, name of medication, dosage and all pertinent instructions.

Plainfield CCSD 202 and its employees and agents are to incur no liability, except for willful and wanton conduct, as a result of any injury arising from the administration or self-administration of medication pursuant to these procedures.

Student InformationNameSchool

Birth DateGrade

LICENSED PRESCRIBER’S ORDER FOR MEDICATION

I have determined that the following medication must be taken during school hours.DrugDosageRouteSide effectsDiagnosis

Start date

Time given

End date

(orders will expire on August 1st if no end date is specified)

Physician’s Signature

Physician’s Phone REQUIRED

PARENT'S REQUEST TO ADMINISTER MEDICATION

I hereby request that Plainfield District 202 administer to my child during school hours, the drug ordered byDr.

Parent phone numbersHome PhoneWork PhoneEmergency Phone

Parent/Guardian Signature

Received by Nurse

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(815) 577-4000 – telephone

Guardianship AffidavitWhen the child does not live with natural or adoptive parent or court ordered guardian.

I.Answers to the following inquiries are necessary in determining residency for school attendance. This form is to be completed by the adult who demonstrates, that he or she has assumed legal responsibility over the student, and provides the student with a regular fixed nighttime dwelling. (Subject to approval by school administration)

II.IF YOU PROVIDE AN ANSWER WHICH YOU KNOW IS FALSE, YOU CAN BE CRIMINALLY PROSECUTED FOR PERJURY.

III. General Information1.

2.

3.4.

5.6.

7.

Name of studentAgeGrade in schoolAddress where student presently lives

Name of MotherWhere does Mother live?

Name of FatherWhere does Father live?

Are parents divorced?

IV.8.9.10.

Who has custody of student?What is the date of the divorce decree?A certified copy of the divorce decree, order of custody and/or joint parenting agreement and any amendments thereto must be furnished.

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V. IF STUDENT IS NOT LIVING WITH A PARENT:11.

12.

13.

14.

15. a.

b.

c.

d.

16.

a.

b.

c.

d.

e.

f.

g.

h.

i.

Name of person(s) with whom the Student lives.

What is your relationship to the student?

Your present address.

Your present phone number.

Does the student live with you full-time?

If part-time, state what portion of time the student lives with you and where and with whom he or she

When did the student begin living with you?

How long do you intend to have the student live with you?

Indicate below the times the student will visit his or her custodial parent at his or her present address during the upcoming year.

Approximately how many nights (including weekends)

Approximately how often at meal times (including weekends)

Approximately how often on weekends

Approximately how often on weekdays

Winter (Christmas) vacation

Spring vacation

Approximately how many school holidays

Summer vacation

Other

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17.

a.

b.

c.

d.

e.

f.

g.

h.

i.

18. State the reason(s) why the student is living with you:

19. List the names and locations of each school the student has attended during the past five years and the dates of attendance.

20. a.

b.

c.

Indicate below the times the custodial parent will visit the student during the upcoming year.Approximately how many nights (including weekends)

Approximately how often at meal times (including weekends)

Approximately how often on weekends

Approximately how often on weekdays

Winter (Christmas) vacation

Spring vacation

Approximately how many school holidays

Summer vacation

Other

Do you own a residence (home)?

If so, what is the address?

Are you occupying your present place of residence as a tenant?

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d.

e.

21. a.

b.

c.

d.

22. a.

b.

c.

d.

23.

24.

a.

b.

c.

If so, give the name and address of your landlord or management company.

How long do you intend to reside at the place where you are presently residing?

Who provides the student’s living expenses and costs?

If living expenses and costs are shared, please indicate the arrangements for sharing such expenses.

Is the person(s) with whom the Student is staying paid any money for food, housing, or for keeping the student?

Do you pay any money for the student?

Who is responsible for the discipline and control of the student?

Does the person(s) with whom the Student is staying have authority to discipline the student?

Who is financially responsible for any damages caused by the student?

In the event of an accident or other emergency, who may direct and consent to medical treatment and sign any releases required?

Briefly state who enrolled the Student in the School District and the reasons why the Student was enrolled in the District.

Do you have court approved custody or guardianship of the student?

If yes, why was the guardianship secured?

Attach copies of any agreements, judgments, decrees or other documents awarding or giving custody of the named student to any person. If to your knowledge there are no such documents, please check below.

No such documents

If not, state the name and address of the person who does:

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25.

26.

27.

28.

29.

30.

31.

a.

b.

32.

33.

Where did the Student reside during the previous summer?

Who declares the Student as a dependent for income tax purpose?

Who is authorized to receive report cards?

Who would attend Parent conferences at the school?

Who would receive notifications in case of Student discipline, suspension or expulsion?

On Saturdays and Sundays, where does the Student stay?

Where does the Student take his or her meals?

From Monday through Friday?

On Saturdays and Sundays?

List the names and ages of any brothers and sisters, where they live and where they attend school.

Name Age Address School Attended

Provide any additional information which may help to establish your residency and the student’s residency or which is otherwise relevant to the question.

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In executing this affidavit, I acknowledge having read and understand the following:

"If a pupil is determined to be a nonresident of the District for whom tuition is required to be charged pursuant to this section, the School Board shall refuse to permit the pupil to continue attending the schools of the District unless the required tuition is paid for the pupil." "A person who knowingly or willfully presents to any School District any false information regarding the residency of a pupil for the purpose of enabling that pupil to attend any school in that District without the payment of a non-resident tuition charge shall be guilty of a Class C Misdemeanor." (105 ILCS 5/10-20.12b)

I understand that if the information provided in connection with this Affidavit is determined to be false or misleading, resulting in the child/children named above to not be legally entitled to attendance in Plainfield Community Consolidated School District 202, the School District will take legal action to recoup valid tuition charges and legal fees.

The Student’s residence within the School District has not been established solely for the purpose of attending the schools thereof. The foregoing facts are sworn to in order to induce the School District to enroll the student in the schools of the District.

I certify that I understand the residency requirements and that I know the penalty for fraudulent registration.

I HEREBY SWEAR THAT THE ANSWERS TO THE FOREGOING QUESTIONS ARE TRUE AND CORRECT AND I UNDERSTAND THAT I MAY BE SUBJECT TO CRIMINAL PROSECUTION FOR PERJURY IF I HAVE KNOWINGLY ANSWERED ANY OF THE QUESTIONS FALSELY.

Signature Date

STATE OF ILLINOIS)

SS.)

COUNTY OF WILL)

I do hereby certify that on the ____ day of __________________, 20____,

Did state on oath that the answers to the questions on the foregoing document were true and correct to the knowledge of the affiant.

Notary Public

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(815) 577-4000 – telephone

Residency Affidavit**must be updated in the spring of each year**

Residency Requirements when the Parent/Legal Guardian does not own or lease the residence, consists of the following:The parent/legal guardian must provide 2 proofs of residency in addition to completing the residency affidavit.AND The homeowner must provide 3 proofs of residency.

Residency Requirements Parent/Legal Guardian: 3 proofs of residency with parent/legal guardian name and current address are required. You will need a notarized residency affidavit as well as to 2 proofs from Category B.

Category AResidency Affidavit - Completed & Notarized

Category BMUST BE ISSUED WITHIN THE LAST

3 MONTHSAuto registrationHomeowners or renters insuranceDriver’s license or state identificationPhoto identification from foreign consulate



Homeowner: 3 proofs of residency in the homeowner’s name with an address within School District 202 boundaries are required, with at least one document from category C and one document from category D.

Category CRecent Real Estate Tax BillLease (signed showing date of occupancy with landlord’s name and phone number)Settlement statement (signed and within 30 days)Truth in lending statement (signed and within 30 days)Warranty deed (within 30 days)Mortgage statement / Payment book (within 30 days)Bill of Sale (within 30 days)Military housing letter

Category DMUST BE ISSUED WITHIN THE LAST

3 MONTHSAuto registrationHomeowners or renters insuranceDriver’s license or state identificationPhoto identification from foreign consulate



Page 29

Residency AffidavitPlainfield Community Consolidated School District 202

PARENTS/GUARDIAN MUST COMPLETE THIS SECTION AND FURNISH TWO (2) PROOFS OF RESIDENCY. SEE CATEGORIES A & BTHIS AGREEMENT AUTOMATICALLY TERMINATES ON THE LAST DAY OF THE 2017-2018 SCHOOL YEARI, verify that my child(ren) and I live at Apt

City Zip CodeOur residence within this district has been established because:

We intend to remain at this residence untilPrevious home phone Previous address Apt

City Zip CodeName of Child Grade District 202 School

I understand residence information may be verified by a home visit and that I must notify the school immediately in writing when I move out. Falsification of residency information on this document will be grounds for removing student(s) from the Plainfield School District and tuition fees will be assessed from the first day of student attendance. I am aware that under Illinois state law that it would be classified a Misdemeanor for Falsification of information and I could face criminal prosecution. I affirm (declare) under penalty of the law that the foregoing is true and correct.ONLY SIGN IN FRONT OF A NOTARY.

Signature of Parent/Legal Guardian Print name of Parent/ Guardian Home Phone

Subscribed and sworn to before me on this ________ day of __________________, 20____

Signature of Notary

Business Phone

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DISTRICT RESIDENT MUST COMPLETE THIS SECTION AND FURNISH THREE (3) PROOFS OR RESIDENCY. SEE CATEGORIES C & D.

I, verify thatand their child(ren)are living with me in my home at Apt

City Zip CodeUtility bills are paid by me. I understand residence information may be verified by a home visit and that I must notify the school immediately, in writing, when the above-named family moves out of my home. I understand that Under the Illinois state law that it would be classified a misdemeanor for falsification of information and I could face criminal prosecution. I affirm (declare) under penalty of the law that the foregoing is true and correct. Enrollment will be terminated immediately should it be determined that the residency requirements are not being met.ONLY SIGN IN FRONT OF A NOTARY.

Signature of District Resident Print Name of District Resident Home Phone

Subscribed and sworn to before me on this ________ day of __________________, 20____

Signature of Notary

Business Phone

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