Please Return to School GRANTSBURG SCHOOL DISTRICT HIGH SCHOOL

Office 2018-2019 Yearly Student Information

Parent/guardian(s) please complete and return to school immediately, this information and any changes are vital for school
records an safety of your child
Student Information
Student’s Legal Full Name
Last First Middle
Place of birth ______________________ _______________ _____________________________________
City State County
Physical Street Address
Mailing Address (if different, such as a PO Box)
Home Phone Land Cell Student Cell Phone # (optional) ____________________
Gender M F DOB Age Grade Level

Ethnicity (Please answer BOTH Questions 1 and 2)

1. Is this student Hispanic or Latino? (Choose one) No, not Hispanic or Latino Yes, Hispanic or Latino
2. Is this student: (Choose one or more) Asian Black or African American
Native Hawaiian or other Pacific Islander American Indian or Alaskan Native White

Primary Language English Other: ______________________________________________________________

Resident Township
Village of Grantsburg Anderson Daniels Grantsburg Lincoln Trade Lake West Marshland Wood River Sterling
Primary Parent(s)/Guardian(s) student resides with: Send Student information to this address

Name (Last, First) Relationship to Student_____________________

Mailing Address (if different from above)
Employer Name Department Shift (if applies) 1 2 3
Daytime Phone_____________________ Cell Home Work Alternate Phone _____________________ Cell Home Work

Name (Last, First) Relationship to Student_____________________

Employer Name Department Shift (if applies) 1 2 3
Daytime Phone_____________________ Cell Home Work Alternate Phone _____________________ Cell Home Work

Family Email _______________________________________________________________

Additional Parent(s)/Guardian(s) Information (such as non-custodial, co-residency, other.)
Does co-residency apply Yes No (Example, resides every other week. If so , please give mileage from home to school __ miles.)
Name (Last, First) Relationship to Student _____________________
Mailing Address _______________________________________________________________________________________________
Send student information to this address
Employer Name Department Shift (if applies) 1 2 3
Daytime Phone_____________________ Cell Home Work Alternate Phone _____________________ Cell Home Work
Email _________________________________________

Name (Last, First) Relationship to Student _____________________

Mailing Address _______________________________________________________________________________________________________
Send student information to this address
Employer Name Department Shift (if applies) 1 2 3
Daytime Phone_____________________ Cell Home Work Alternate Phone _____________________ Cell Home Work
Email _________________________________________
Please indicate which of the following items you would like the non-custodial parent to receive.
Report Cards Only All school related information
I authorize the above non-custodial parent permission to allow our student to leave school.
I authorize the above non-custodial parent to give permission in the case of an emergency.

The High School will send student information to only 2 addresses. Please check which addresses to send to.
Emergency Contacts
Please designate (3) relatives/neighbors/friends (if you cannot be reached) to authorize us to release your child in case of illness or
emergency. These contacts are for emergency/illness use only.

Contact 1
Name Relationship
Phone Cell Home Work Alternate Phone Cell Home Work
Contact 2
Name Relationship
Phone Cell Home Work Alternate Phone Cell Home Work
Contact 3
Name Relationship
Phone Cell Home Work Alternate Phone Cell Home Work

Transportation Information Will your child need Transportation? Yes ___ No ___

If yes, where do you want your child to be picked-up?

Home ___ Some other Place ___ Address __________________________________________

Where do you want your child to be dropped?

Home ___ Some other place ___ Address __________________________________________

I will drop off and pick up my child ___ My child will drive to/from school ____

ALC ___ (bus from HS to Siren and back. (T, W, TH)

Connect 5 System Please indicate the contact numbers you wish to have in the Connect 5 System
This is the automated system for school delays, closing, and announcements
Phone #1: _________________________________ # 1 Contact Name: ___________________________________
Phone #2: ________________________________ # 2 Contact Name: ___________________________________
Phone #3: ________________________________ # 3 Contact Name: ___________________________________
E-mail # 1(if desired) _____________________________ E-mail # 2(if desired) ___________________________________________

Health Information
MEDICATION:
Is medication needed at home? Yes No Medication name & dosage
Is medication needed at school?* Yes No Medication name & dosage

*If your child needs prescription medication during the school day, please contact the school office for necessary
forms for you and your doctor’s office to complete as required by state law.
Also, non prescription medications kept at school will need completion of necessary forms by a parent/guardian.

Please indicate below any allergies or medical conditions that the school should be aware of in regards to your student.

I will make arrangements for proper care in case my child should meet with an accident or become too ill to remain at school at
a time I am away from home. In case of EMERGENCY our procedure will be to contact the parent at home or work. If
unable to contact parents, I authorize the principal, teacher or health room personnel to call 911.

Form completed by: __________________________________________ Relationship to student: ________________

Parent/Guardian Signature: __________________________________________________ Date: ________________