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708 758 5190 (District)
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201 e. glenwood-dyer rd | glenwood, il 60425
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Information
Powerschool ID
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Parent/Legal Guardian #1
First Name
Middle Initial
Last Name
Addr1
Addr2
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Phone
Best Daytime Phone #
Email
Employer
Name of Employer
Work Phone #
Parent/Legal Guardian #2
First Name
Middle Initial
Last Name
Addr1
Addr2
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State
Zip
Phone
Best Day Time Phone #
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Name of Employer
Work Phone #
Siblings Attending Brookwood School District 167
Student First Name
Student Middle Initial
Student Last Name
Birth Date
Grade
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Pre-K
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8th
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Longwood
Hickory Bend
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Sibling #2
Student First Name
Student Middle Initial
Student Last Name
Birth Date
Grade
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Pre-K
1st
2nd
3rd
4th
5th
6th
7th
8th
School
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Longwood
Hickory Bend
Middle School
Junior High
Sibling #3
Student First Name
Student Middle Initial
Student Last Name
Birth Date
Grade
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Pre-K
1st
2nd
3rd
4th
5th
6th
7th
8th
School
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Longwood
Hickory Bend
Middle School
Junior High
Sibling #4
Student First Name
Student Middle Initial
Student Last Name
Birth Date
Grade
Please Select...
Pre-K
1st
2nd
3rd
4th
5th
6th
7th
8th
School
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Longwood
Hickory Bend
Middle School
Junior High
Parental Status
Parent Status
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Married
Separated
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Sole Custody (Must have signed court papers)
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Mother Deceased
Father Deceased
Child Resides With
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Both Natural Parents
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One Natural & One Stepparent Grandparents
Foster Parents
Mother Only
Father Only
Guardian
Sole Custody
Mother
Father
Visitation Restrictions
**Visitation Restrictions (check if applicable): OFFICE MUST HAVE A COPY OF THE ORDER. Visitation Restrictions; If one of the parents is restricted from visiting this child, please attach a copy of the court order to this emergency card. The court order copy will be placed in the student’s file. The schools can only honor court orders.
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