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Student Information
Registration for Ford Heights School District 169, School Year 2021-2022
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Student State ID Number (To be completed by the school)
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School
*
Cottage Grove Upper Grade Center (5, 6, 7, 8)
Medgar Evers Primary Academic Center (K, 1, 2, 3, 4)
PPS (Pre-K, 1, 2, 3, 4,, 5, 6, 7, 8)
Early Childhood (Pre-K for all)
Student Name (First, Middle, Last)
*
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Student Grade (registering for)
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Student Date of Birth
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MM
/
DD
/
YYYY
Parent Email
*
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Mother's Name (Last, First)
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Mother's Maiden Name
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Father's Name (Last, First)
*
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Street Address
*
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City
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State
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Zip Code
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Home Phone (xxx) xxx-xxxx
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Parent's Social Security xxx-xx-xxxx
*
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LIST ALL SIBLINGS IN THE HOUSEHOLD BELOW
Sibling 1 (Last, First, Middle, D.O.B, Grade)
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Sibling 2 (Last, First, Middle, D.O.B, Grade)
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Sibling 3 (Last, First, Middle, D.O.B, Grade)
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Sibling 4 (Last, First, Middle, D.O.B, Grade)
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Sibling 5 (Last, First, Middle, D.O.B, Grade)
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Sibling 6 (Last, First, Middle, D.O.B, Grade)
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