Steeleville School District 138

Student's Information

First Name

Middle Name

Last Name

Enrollment Date

Sex

Grade

Date of Birth

Place of Birth

Race

Current Address

School Email Address

Student's Phone Number

Status

Father's Information

Father's Name

Father's Employer

Father's Home Address

Father's Email Address

Father's Home Number

Father's Cell Number

Father's Work Number

Mother's Information

Mother's Name

Mother's Employer

Mother's Home Address

Mother's Email Address

Mother's Home Number

Mother's Cell Number

Mother's Work Number

Mother's Maiden Name

Additional Information

Student Lives With:

Guardian's Name

Guardian's Work Number

If parents cannot be reached call:

Name

Relationship

Phone Number

Name

Relationship

Phone Number

Name

Relationship

Phone Number

Physician's Name

Physician's Phone Number

Does your child take any prescription medications?

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Is your child allergic to any foods, medication, insect bites etc.?

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Does your child have an IEP or receive any special services?

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Date

Steeleville Grade School

Steeleville Grade School

609 S. Sparta St. | Steeleville, IL 62288 | Phone: (618) 965-3469 | Fax: (618) 965-3490

Student Registration Form

Student Registration Form

Student's Information

Student's Information

Father's Information

Father's Information

Mother's Information

Mother's Information

Additional Information

Additional Information

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