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708 758 5190 (District)
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201 e. glenwood-dyer rd | glenwood, il 60425
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residency
Student’s Name (Please use the student’s legal name as it appears on their birth certificate)
Powerschool ID
Student First Name
Student Middle Name
Student Last Name
Student Information
Date of Birth
Gender
Please Select...
Male
Female
Grade
Please Select...
Pre-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
IEP (Individualized Educational Plan)
Yes
No
504 Plan
Yes
No
With whom does the student(s) reside?
First Name
Last Name
Relationship
Please Select...
Grandmother
Grandfather
Godfather
Godmother
Family Friend
Aunt
Uncle
Cousin
Brother
Sister
Niece
Nephew
Mother
Father
Parent
Addr1
Addr2
City
State
Zip
Best Daytime Phone #
Email
I affirm that the information presented in this verification form, in connection with any investigation of my residency or the residency and custody of the student, is true, complete and accurate.
I understand that knowingly or willfully providing false information to the school district regarding the residency of a child for the purpose of enabling that child to attend any school in that district without the payment of nonresident tuition is a Class C misdemeanor.
I understand that knowingly enrolling or attempting to enroll a child in the school of a school district on a tuition-free basis when I know the child to be a nonresident of the school district, unless the nonresident child has a lawful right to attend, is a Class C misdemeanor and I will be liable for payment of tuition, fees, and all other applicable fines.
I certify to the best of my knowledge that the above information is true and accurate. I understand that if my residency is in question, I may be investigated.
submit the form
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