This form is used when the child is not living with a natural or adoptive parent.  It must be completed by the individual who has assumed custody. Read Important Warning and submit this form with your signature to the Building Principal.  The School District reserves the right to evaluate the evidence presented and require further documentation.  Completing this form does not guarantee admission.

Please check all applicable boxes:

☐    The child lives with me at my residence address

    The child lives with me because:                                 

    The child will be leaving with me until:                             

☐    I have assumed and exercise full legal responsibility for and control of the child regarding daily educational and medical decisions, including responsibility for: (attach copies of any agreements, judgements, decrees, or other documentation giving you custody)

    ☐ medical decisions and costs                    ☐ food and clothing

    ☐ discipline and restitution for vandalism or other crimes        ☐ school fees (books, bus, etc.)

At my residence the child regularly:  (Please explain any unchecked boxes)

    ☐ Eats meals                                         

    ☐ Sleeps     nights/week (explain if less than 7 nights per week)                  

    ☐ Spends weekends and summers/school breaks                        

Important Warning: If a student is determined to be a nonresident of the District for whom tuition must be charged, the persons enrolling the student are liable for non-resident tuition from the date the student began attending a District school as a non-resident.

A person who knowingly enrolls or attempts to enroll in this School District on a tuition-free basis a student known by that person to be a nonresident of the District is guilty of a Class C misdemeanor, except in very limited situations as defined in State law. (105 ILCS 5/10-20.12b(e)).

A person who knowingly or willfully presents to the School District any false information regarding a student‘s  residency to enable that student to attend any school in the District without the payment of a nonresident tuition charge is guilty of a Class C misdemeanor. (105 ILCS 5/10-20.12b(f)).

Optional:  To be completed by the natural or adoptive parent(s), if one is available.

Please check all applicable boxes:

☐    I am the natural or adoptive parent of the child.

☐    I have willingly transferred full custody and control of, as well as responsibility for this child to (attach copies of any agreements, judgements, decrees or other documents giving the person named below custody)                                        

☐    I have transferred custody and control of my child to the above-named person because: