Heavilin Elementary School New Student Information 2017-18
Please complete and submit the information below to enroll your child
STUDENT'S Last Name
Your answer
STUDENT'S First Name
Your answer
Preferred Name
Example: Michael - Mike
Your answer
Gender
Student's Date of Birth
Student must be 5 years old prior to August 1, 2017 to attend kindergarten
MM
/
DD
/
YYYY
Student's Birth City:
Your answer
Student's Birth State:
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Ethnicity
Check all that apply
Required
Student's House Number
Example: 305
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Student's Street Name
Example: Franklin St - please use abbreviation Ave, Ct, Dr, Ln, Pkwy, Pl, Rd, St, Ter
Your answer
Apartment
Example: 1/A
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Student's Zip Code
Student Primary Contact Number
Enter Primary Number In This Format: 219-531-3000
Your answer
Select Phone Type
Custodial Parent Last Name, Father's First Name/Mother's First Name
Example: Smith, Jane/John
Your answer
Custodial Parent Relationship
Custodial Parent's Email Address
Type: 'None' if you do not have email
Your answer
Non-Custodial Parent's Email Address
Your answer
Mother's Last Name
Your answer
Mother's First Name
Your answer
Mother's Primary Contact Number
Enter Primary Number In This Format: 219-531-3000
Your answer
Select Phone Type
Father's Last Name
Your answer
Father's First Name
Your answer
Father's Primary Contact Number
Enter Primary Number In This Format: 219-531-3000
Your answer
Select Phone Type
Is Engish the primary language spoken at home?
List other language(s) spoken at home
Your answer
Does your child have any special needs
Has your child been evaluated or received services from Porter County Educational Services?
Please let us know if they attend SELF now or have in the past
Your answer
Describe any special needs information
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Does your child have siblings at this or any other VCS school?
Names and Grade of Siblings
Sibling Name: Last, First & Grade
Your answer
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