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Totally Kids

Lennox School District 41-1 Registration

Family Address:

Street Address
Mailing Address
City
State/Province
Zip/Postal Code
Home Phone
Cell Phone

Mother/Legal Guardian Information:

First Name
Last Name
Middle Initial
E-mail

Mother/Legal Guardian Work Information:

Organization
Work Phone

Father/Legal Guardian Information:

First Name
Last Name
Middle Initial
E-mail

Father/Legal Guardian Work Information:

Organization
Work Phone

Daycare Provider:

Organization
Street Address
Mailing Address
City
State/Province
Zip/Postal Code
Work Phone

Children Require Busing?

Yes No

First Student:

First Name
Last Name
Middle Initial
Date of Birth
Social Security Number
Sex	Male Female
Ethnicity	Caucasion Hispanic African American Native American Hawaiin/Pacific Islander Asian Other
Grade Level	Pre-K K 1 2 3 4 5 6 7 8 9 10 11 12
Previous School
Teacher Name

Child lives with:

Select One Father Mother Father and Mother Legal Guardian Step-Parent(s) Grandparent(s) Other

Bad Weather Contact:

First Name
Last Name
Middle Initial
Street Address
Mailing Address
City
State/Province
Zip/Postal Code
Work Phone
Home Phone

Second Student:

First Name
Last Name
Middle Initial
Date of Birth
Social Security Number
Sex	Male Female
Ethnicity	Caucasion Hispanic African American Native American Hawaiin/Pacific Islander Asian Other
Grade Level	Pre-K K 1 2 3 4 5 6 7 8 9 10 11 12
Previous School
Teacher Name

Child Lives With:

Select One Father Mother Father and Mother Legal Guardian Step-Parent(s) Grandparent(s) Other

Bad Weather:

First Name
Last Name
Middle Initial
Street Address
Mailing Address
City
State/Province
Zip/Postal Code
Work Phone
Home Phone

Third Student:

First Name
Last Name
Middle Initial
Date of Birth
Sex	Male Female
Social Security Number
Sex	Male Female
Ethnicity	Caucasion Hispanic African American Native American Hawaiin/Pacific Islander Asian Other
Grade Level	Pre-K K 1 2 3 4 5 6 7 8 9 10 11 12
Previous School
Teacher Name

Child Lives With:

Select One Father Mother Father and Mother Legal Guardian Step-Parent(s) Grandparent(s) Other

Bad Weather:

First Name
Last Name
Middle Initial
Street Address
Mailing Address
City
State/Province
Zip/Postal Code
Work Phone
Home Phone

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Lennox School District 41-4
Copyright © 2008 [District 41-4]. All rights reserved.
Revised: 02/22/10