Header RDS Parent Access
* Field is required
Request for Enrollment
Filling out this form does NOT guarantee enrollment in an East Chicago Public school. Please fill out this enrollment form and you will be contacted once we have processed your form. There are a limited amount of seats open for Pre-k.
Student Last Name *
Student First Name *
Student Middle Name  
Grade *
Gender *
Birthdate * mm/dd/yyyy
Student Social Security
Place of Birth (City/State) *  
Address *
Apartment  
City/State *  
Zip *
Home Phone *
Lives With *
     
Mother/Father *
You must enter information for at least one parent.
Mother Last Name
Mother First Name  
Mother Phone
Mother Email
Mother Address
(if different from student)
Mother Apartment  
Mother City/State  
Mother Zip  
     
Father Last Name
Father First Name  
Father Phone
Father Email
Father Address
(if different from student)
Father Apartment  
Father City/State  
Father Zip  
Work Information
  Employer Name Address City/State Phone
Mom Work  
Dad Work  
Emergency/Contact Information
  Name Address City/State Phone
1  
2  
3  
4  
Doctor Name  
Doctor Phone
Dentist Name  
Dentist Phone
Babysitter/Daycare  
Babysitter/Daycare Phone
Last School Attended *
School Name
(enter "none" if no last school)
City/State  
Phone
Ethnicity *
Check all that apply. You must check at least one.
   
   
   
   
   
   
Siblings Enrolled at This District
Name School Grade
Comments or Additional Information
Signature
Your Name *
 
     
     
     
         
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