Steeleville School District 138

Student's Information

First Name

Middle Name

Last Name

Enrollment Date

Enrollment ID

Sex

Grade

Date of Birth

Place of Birth

Race

Birth Certificate No

Social Security #

Current Address

School Email Address

Student's Phone Number

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

Is parent or guardian a member of the armed forces?

Is so, are they deployed or expected to be deployed?

Student Lives With:

Guardian's Name

Guardian's Work Number

If parents cannot be reached call:

Name

Relationship

Phone Number

Address

Name

Relationship

Phone Number

Address

Physician's Name

Physician's Phone Number

Does your child take any prescription medications?

List Prescription Medication:

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

List Allergies:

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

Previous School's Name

Previous School's Phone Number

Previous School's Address

Print your Name

Date

Steeleville High School

Steeleville High School

701 S. Sparta St. | Steeleville, IL 62288 | Phone: (618) 965-3432 | Fax: (618) 965-3433

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

To submit multiple responses, you must refresh your page and add the next enteries information.