Checklist for Enrolling a New Student

Checklist for Enrolling a New Student
 Complete the forms included in the registration packet
 Bring appropriate documentation for Proof of Residency – You must provide at least one document listed in
Category A or at least two documents listed in Category B along with the signed Affidavit of Residency
(included in the registration packet).
Category A – Attach a copy of at least one of the following documents:
 Signed lease for my residence.
 Signed real estate contract or closing statement for the purchase of a residence showing closing date
prior to the first day of school.
 A home construction contract showing expected completion date. (Note: Residence status must be
determined. Please contact Dr. Julie-Ann Fuchs, Assistant Superintendent for Business at 630-365-5111)
 An affidavit from the owner of your residence stating that you reside at the residence on a full time
basis.
Category B – Attach a copy of at least two of the following documents:
 Driver’s license
 Gas or electric bill
 Public Aid card
 Voter registration card
 Home/apartment insurance certificate
 Automobile registration from State of Illinois
 Birth Certificate – County issued certified original with seal (hospital copy will not be accepted) as required
by the Missing Children Records Act [325 ILCS 50/5b] and the Missing Children Registration Law [325 ILCS
55/5b].
 Appropriate Medical Forms (see packet)
 Current IEP or any other Special Ed. Records (if applicable)
 Illinois State Board of Education Transfer Form ISBE 33-78 – if transferring from a public school within the
state of Illinois. This document must be provided by the previous school.
 Copy of Divorce Decree and/or Orders of Protection (if applicable)
 If you are not the student’s parent or legal guardian and have assumed responsibility for a student for reasons
other than access to the educational programs of the school district, please contact the school.
 If your student will be enrolling in Grades 6-12, you must call the school in advance to schedule an
appointment.
Kaneland Harter Middle School (Grades 6–8) 630-466-8400 ext. 77102
Kaneland High School (Grades 9–12) 630-365-5100 ext. 210
 Note: Your student will attend school 48 hours after the registration materials are received in the school
office.
KANELAND COMMUNITY SCHOOL DISTRICT #302
STUDENT ENROLLMENT FORM – GRADES EC-12
For Office Use Only: School Name_______________ ID# ________________ Homeroom_______________
Date Completed:
Entry Date:
Last Name:
First Name:
Middle Name:
Nickname (if applicable):
(to be called at school)
Grade Level:
Date of Birth:
Place of Birth:
City/State or City/Country
Gender (Circle One):
Male or Female
Residence Address:
Street Address (must be provided)
City:
PO Box (if applicable)
State:
Zip Code:
Other siblings enrolled in District 302 and their grade level:
PRIMARY CONTACT INFORMATION
Child lives with (check one):
Both Parents 
Mother and Stepfather *  Father and Stepmother* 
Mother Only 
Father Only 
Other  (Must complete affidavit)
Mother/Step-mother/Guardian (Circle One)
Last Name:
First Name:
Maiden Name (optional):
Home Phone #:
Work #:
Cell #:
Email Address:
Father/Step-father/Guardian (Circle One)
Last Name:
Home Phone #:
First Name:
Work #:
Cell #:
Email Address:
Primary Contact(s) Address:
Street Address (must be provided)
City:
State:
PO Box (if applicable)
Zip Code:
*Does the stepparent have the right to make educational choices regarding the student? Yes  No 
Signature of custodial parent_______________________________________________
Non-Custodial Parent Information
Is the non-custodial parent legally prohibited from picking up/visiting the child? (check one) Yes*  No 
Is the non-custodial parent legally prohibited from receiving mailings? (check one) Yes*  No 
*If yes, please bring to school the current court order so we may make a copy of it.
Last Name:
First Name:
Street Address:
Email address:
City:
State:
Home Phone #:
Zip:
Cell # :
Work #:
PRIOR EDUCATION
*PLEASE INCLUDE ANY PRIOR EDUCATION INCLUDING PRESCHOOL*
Previous School Name:
Phone #:
School Address:
Fax #:
Street Address is needed
City:
State:
Records Request Form Complete?: Yes 
Kindergarten Parents Only:
Did your child attend preschool? Yes  No 
Zip Code:
No 
If yes, where?
Services Received at Previous School (if applicable):
Gifted  ELL / ESL  Reading 
Social Work  504 Plan  Other 
:
Special Education (if applicable): IEP  Speech IEP  Case Study Pending 
EMERGENCY CONTACT INFORMATION
If we are unable to contact parents/guardians in case of illness, injury or emergency, please list at least one
additional contact to whom we may release your child:
Name:
Relationship:
Phone #:
Name:
Relationship:
Phone #:
Name:
Relationship:
Phone #:
Chronic Medical Condition(s) and/or medications:
This form was completed by:
Signature
Date
Your signature certifies that all information is correct to the best of your knowledge. If you move during the school year, please notify the school immediately
of your expected last day.
FOR OFFICE USE ONLY:
Birth Certificate  Proof of Residency  Affidavit of Residency 
Home Language Survey 
Race/Ethnicity Form 
To Nurse: Information sheet  _______ Physical  ________
Internet Authorization Form 
Dental form  _______
To Transportation: Alternate Transportation Form  _______
Records Requested: _____________
Second Request: _____________ Sp.Ed. Records Requested  yes  no
Bus Route A. M. _______P. M. ________Locker __________
Revised 1/2015
Home Language Survey English
Under the law P.L. 98-511, the state requires the district to collect a Home Language Survey for every
new student. This information is used to count the students whose families speak a language other than
English at home. It also helps to identify the need for bilingual and English as a Second Language
education services in the schools. “Home Language means that language normally used in the home
by the student and/or by the student’s parents or legal guardians.”
Please answer the questions below and return this survey to your child’s school.
Student’s Name: __________________________________________
1. Is a language other than English spoken in the home?
_____ Yes What language? ___________________________
_____ No
2. Does your son/daughter speak a language other than English?
_____ Yes
_____ No
What language? ___________________________
If the answer to either question is yes, the school will assess your child’s English language proficiency as
required by state law.
__________________________________________________________________ _______________
Signature of Parent/Guardian
Date
Bajo la ley P.L. 98-511, el estado exige que el distrito haga una Encuesta Sobre el Idioma Que Se
Habla en la Casa. Esta información se utiliza para contar los estudiantes cuyas familias hablen un
idioma que no sea inglés en su casa. También ayuda a identificar la necesidad de programas de
instrucción bilingüe y de inglés como segundo idioma en las escuelas. “El idioma del hogar significa el
lenguaje hablado normalmente en el hogar por el estudiante y/o por los padres del estudiante o
guardianes legales. "
Tenga la bondad de contestar las siguientes preguntas y de devolver la encuesta a la escuela de su hijo/a.
Nombre del alumno: ______________________________________________
1. En su casa ¿hay alguna persona que hable algún otro idioma que no sea inglés?
_____ Sí ¿Qué idioma? _____________________________
_____ No
2. ¿Habla su hijo/a otro idioma que no sea inglés?
_____ Sí ¿Qué idioma? _____________________________
_____ No
Si la respuesta a cualquiera de las preguntas es “sí”, su hijo, como es requerido por la ley estatal, será
examinado para medir la capacidad del dominio del idioma inglés.
________________________________________________________________ _______________
Firma del Padre o Tutor
Fecha
U.S Department of Education Race and Ethnicity Data Standards
Student’s Name ____________________________________________________
Instructions:
This form is to be filled out by the student’s parents or guardians, and both questions
must be answered. Part A asks about the student’s ethnicity and Part B asks about the student’s race. If
you decline to respond to either question, the school district staff is required to provide the missing
information by observer identification.
Part A. Is this student Hispanic/Latino? Choose only one
o
o
No, not Hispanic/Latino
Yes, Hispanic/Latino
The question above is about ethnicity, not race. No matter which answer you selected, continue and
respond to the question below by marking one or more boxes to indicate what you consider the
student’s race to be.
Part B. What is the student’s race? Choose one or more
o
American Indian or Alaska Native A person having origins in any of the original peoples
of North and South America, Including Central America, and who maintains tribal
affiliation or community attachment.
o
Asian A person having family origins in any of the original peoples of the Far East,
Southeast Asia or the Indian subcontinent including for example Cambodia, China, India,
Japan, Korea, Malaysia, Pakistan, The Philippine Islands, Thailand and Vietnam.
o
Black or African-American A person having family origins from: o Black racial groups of
Africa
o
Hawaii Native or other Pacific Islander A person having family origins in any of the
original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
o
White A person having family origins in any of the original peoples of Europe, the
Middle East, or North Africa.
Note: Data collected on this form must be maintained by the school district for three years. However, when there is litigation, a
claim, an audit, or another action involving this record, the original responses must be retained until the completion of the
action.
Illinois State Board of Education, Division of Data Analysis and Progress Reporting
KANELAND TRANSPORTATION DEPARTMENT (630) 365-5111, EXT. 148
“Does your child get picked up or dropped off at a house other than yours?” – Please RESPOND
Dear Parents:
If your child will be picked up or dropped off daily at a bus stop other than at your assigned bus stop near
your home address, during the next school year, please fill out the form below with the necessary
information.
Important: All information from previous years will be eliminated, and therefore everyone using a
regular alternative pick-up or drop-off site must fill out this form every year for each child.
We need the fire number or street address of the alternative site in order to assign the correct bus route.
Please return this form to the Transportation Department as soon as possible, but not later than July 1.
You may return this form to your child’s teacher until the end of the school year.
Thank you for your cooperation.
Kaneland Director of Transportation
Please use the grade and school for the 2015-2016 school year:
Student Name:
Grade:
School Name:
Name of person or daycare facility for AM pickup:
Address of AM alternate site:
Will the facility supply AM transportation? Yes 
No 
Name of person or daycare facility for PM pickup:
Address of PM alternate site:
Will the facility supply PM transportation? Yes 
No 
Effective date:
Parent signature:
Home Phone:
Alternate Phone:
Revised January 2015
KANELAND COMMUNITY UNIT SCHOOL DISTRICT #302
Business Office
47W326 Keslinger Road
Maple Park, Illinois 60151
Phone: (630) 365-4119
Fax: (630) 365-9428
Military Children Registration Form
Dear Parent or Guardian:
Please take a few moments to answer these voluntary questions. The purpose of this form is to
help identify Illinois military families (Public Act 97-505).
Your participation will help schools get U.S. Department of Defense assistance for children
struggling with their parent’s or guardian’s military deployment.
Name(s) of Child(ren) in School:
1.
2.
3.
4.
5.
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
Does the child(ren)’s parent or guardian serve in the military, including National Guard or
Reserve?
_____ YES
_____ NO
Is the parent or guardian currently serving on active duty or expect to be deployed this year?
_____ YES
_____ NO
Has a parent or guardian returned from deployment in the last six (6) months?
_____ YES
_____ NO
Thank you for your participation. Please return this survey to your child(ren)’s school office.
PERMISSION TO TRANSFER STUDENT RECORDS
Name of last school attended
Address (if known)
City, State, Zip
Phone #
Fax #
Please release to Kaneland CUSD #302 all records for past and present grades for the following student(s) to include
but not limited to:
Academic Records, Health Records, IEP information, Spec. Education, and any other pertinent permanent and
temporary information required by law.
Name of Student(s)
Date of Birth
Grade
As parent/legal guardian of the student listed above, I authorize release of temporary and permanent records to
Kaneland Schools.
Signature of Parent/Guardian
Date
Illinois law requires the District to transfer student’s records within ten (10) days of receiving a request from the new school in which the student is
transferring to. Prior to releasing the records, the Parent/Guardian has the right to inspect, copy, and challenge the contents of the records. 105 ILCS
10/6, 10-8 Illinois School Student Records Act.
Please send information to (check one):

John Stewart Elementary
817 Prairie Valley Street
Elburn, IL 60119
Phone (630) 365-8170
Fax (630) 365-0651

John Shields Elementary
85 Main Street
Sugar Grove, IL 60554
Phone (630) 466-8500
Fax (630) 466-5320

Blackberry Creek Elementary
1122 S. Anderson Road
Elburn, IL 60119
Phone (630) 365-1122
Fax (630) 365-3905

McDole Elementary School
2901 Foxmoor Drive
Montgomery, IL 60538
Phone (630) 897-1961
Fax (630) 897-3229
*All Special Education records for Kaneland CUSD #302 should be addressed to: Director of Special Education, Kaneland School District,
47W326 Keslinger Rd. Maple Park, Il 60151
Date:
_____________________ ____________________
1st request
2nd request
User Name: _______________________________
(Please Print)
Kaneland CUSD #302 - Acceptable Use Policy
Authorization for Network Access
Any person (i.e., full-time and part-time employees, students, substitute or student teachers, Board members,
volunteers, citizens) using the district’s network, shall use this resource only for school- and education-related
purposes consistent with the goals of Kaneland CUSD 302. These include but are not limited to facilitating
teaching and learning through resource sharing, innovation, and communication. Accessing the network
through the District’s computer system is a privilege that is granted, revoked or restricted at the discretion of the
Board of Education through the administration. Misuse of the District’s network access through, for example,
unacceptable uses, violation of network etiquette, safety or security, vandalism or copyright infringement, may
result in revocation or restriction of access to this resource. Specific terms and conditions for accessing the
District’s network are available in the administrative procedures, which are attached to this document and can
be obtained in the main office at any Kaneland School. All users must sign this form indicating they agree and
will abide to the terms and conditions contained within the administrative procedures.
Kaneland Student, Employee or Other Network User:
I understand and will abide by the above Authorization for Network Access. I further understand that should I
commit any violation, my access privileges may be revoked and school disciplinary action and/or appropriate
legal action may be taken. In consideration for using the District’s network and having access to public
resources, I hereby release the School District and its Board members, employees, and agents from any claims
and damages arising from my use, or inability to use the District network or Internet.
USER SIGNATURE: ___________________________
DATE: __________________
(Required if the user is a student):
I have read this Authorization for Network Access. I understand that access is designed for educational
purposes and that the District has taken precautions to eliminate controversial material. However, I also
recognize it is impossible for the District to restrict access to all controversial and inappropriate materials. I
will hold harmless the District, its employees, agents, or Board members, for any harm caused by materials or
software obtained via the network. I accept full responsibility for supervision if and when my child’s use is not
in a school setting. I have discussed the terms of this Authorization with my child. I hereby request that my
child be allowed access to the District’s network or Internet.
PARENT/GUARDIAN NAME:
(Please Print)
STUDENT NAME:
(Please Print)
PARENT/GUARDIAN SIGNATURE:
DATE:
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KANELAND COMMUNITY UNIT SCHOOL DISTRICT #302
Administrative Procedures for Access to the District Network (Internet Safety Policy)
All Kaneland employees and students (and their parents or guardians) must sign the Authorization for Network Access as a
condition for using the District’s Network and Internet connection. School Board members, administrators, community
members and parents are treated like employees for the purposes of the Authorization. Please read this document carefully
before signing the Authorization for Network Access form.
All use of the District’s Internet access shall be consistent with the District’s goal of promoting educational excellence by facilitating
resource sharing, innovation, and communication. This Authorization does not attempt to state all allowed, required or proscribed
behaviors by users. However, some specific examples are provided. The failure of any user to follow the terms of the Authorization
for Network Access may result in the loss of privileges, disciplinary action, and/or appropriate legal action. The signatures on the
Authorization for Network Access form are legally binding and indicate the signers have read the terms and conditions carefully and
understand their significance.
Terms and Conditions
1.
Acceptable Use –The District’s Internet access must be used for the purpose of education or school-related research, and be
consistent with the educational objectives of the District.
2.
Privilege of Use – Using the District’s Internet access is a privilege, not a right, and inappropriate use may result in cancellation
of those privileges. The system administrator and/or school principal will make all decisions regarding whether or not a user has
violated this Authorization and may deny, revoke, restrict or suspend access at any time.
3.
Unacceptable Use – You are responsible for your actions and activities involving the network. Some examples of unacceptable
uses are:
a. Using the network for any illegal activity, including “hacking”, violation of copyright or other contracts, or transmission of
any material in violation of any U.S. or State regulation;
b. Unauthorized downloading or loading of software;
c. Using unauthorized copyrighted materials or any other materials in violation of state, federal or international copyright laws;
d. Using the network for private financial or commercial gain, including advertising;
e. Wastefully using resources, such as network bandwidth and/or storage space;
f. Using of any unauthorized personal equipment attached, connected, and/or installed to district network;
g. Invading the privacy of individuals by unauthorized disclosure, use or dissemination of personal information;
h. Using another user’s account or password;
i. Posting material authored or created by another without his/her consent, including anonymous messages;
j. Using the network to obtain, solicit or distribute information that could potentially incite illegal activity including violence,
harassment, stalking or terrorist activity;
k. Using profanity, obscenity or language that is possibly considered offensive or threatening to persons of a particular race,
gender, religion, sexual orientation, or to persons with disabilities;
l. Using the network while access privileges are suspended or revoked;
m. Tampering with any electronic records, software, or equipment; and
n. Gaining any form of unauthorized access to resources or entities, as stated above or otherwise.
4.
Network Etiquette – You are expected to abide by the generally accepted rules of network etiquette. These include, but are not
limited to, the following:
a. Be polite. Do not become abusive in your messages to others.
b. Use appropriate language. Do not swear or use vulgarities or any other inappropriate language.
c. Keep personal information, including the logins, passwords, addresses, and telephone numbers of students or colleagues
confidential.
d. Recognize that electronic mail (e-mail) is not private. People who operate this system have access to all mail. Messages
relating to or in support of illegal activities may be reported to the authorities.
e. Use these resources so as not to disrupt service to other authorized users.
f. Consider all communications and information accessible via the network to be private property.
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5.
No Warranties – The District makes no warranties of any kind, whether expressed or implied, for the service it is providing. The
District will not be responsible for any damages you suffer. This includes loss of data resulting from delays, non-deliveries,
missed-deliveries, or service interruptions caused by its negligence or your errors or omissions. Use of any information obtained
via the Internet is at your own risk. The District specifically denies any responsibility for the accuracy or quality of information
obtained through its services.
6.
Indemnification – The user agrees to indemnify the School District for any loss, costs, or damages, including reasonable attorney
fees, incurred by the District relating to, or arising out of, any breach of this Authorization.
7.
Internet Safety – Pursuant to the Children's Internet Protection Act, Kaneland uses filtering software to screen Internet sites for
offensive material. Users are cautioned that many internet sites contain offensive, sexually explicit, and inappropriate material,
including, but not limited to the following categories: Adult Content; Nudity; Sex; Gambling; Violence; Weapons; Hacking;
Personals /Dating; Lingerie/Swimsuit; Racism/Hate; Tasteless; and Illegal/Questionable. In general it is difficult to eliminate all
contact with this type of material while using the Internet. Even innocuous search requests may lead to sites with highly offensive
content. Additionally, having an e-mail address on the Internet may lead to receipt of unsolicited e-mail containing offensive
content. Authorized users accessing the Internet do so at their own risk. No filtering software is one hundred percent effective and
it is possible that the software could fail. In the event that the filtering software is unsuccessful and children and staff gain access
to inappropriate and/or harmful material, the Board will not be liable. To minimize these risks, use of the Kaneland Network is
governed by this policy.
8.
Vandalism – All authorized student users are to report promptly any violations of this policy to their teacher or school principal.
The teacher or school principal will report such violations to the Technology Director or designee of the Kaneland Public Schools
in order to ensure network security.
In order to maintain the security of the Kaneland System, authorized users are prohibited from engaging in the following actions:
a. Intentionally disrupting the use of the Kaneland Network for other users, including, but not limited to, disruptive use of any
processes or programs, sharing logins and passwords or utilizing tools for ascertaining passwords, spreading computer
viruses, engaging in "hacking" of any kind, use of proxy or filter avoidance software or devices, and/or engaging in computer
tampering of any kind.
b. Violating standard security procedures. Network security is a high priority. If you can identify a security problem on the
network, you must notify a system administrator. Do not demonstrate the problem to other users. Keep your account and
password confidential. Do not use another individual’s account. Attempts to log on to the network as a system administrator
will result in cancellation of user privileges. Any user identified as a security risk or having a history of problems with other
computer systems may be denied access to the network.
9.
Copyright Web Publishing Rules – Copyright law and District policy prohibit the republishing of text or graphics found on the
Web or on District Web sites or file servers without explicit written permission.
a. For each republication (on a Web site or file server) of a graphic or a text file that was produced externally, there must be a
notice at the bottom of the page crediting the original producer and noting how and when permission was granted. If
possible, the notice should also include the Web address of the original sources.
b. Students and staff engaged in producing web pages must acquire and retain proof of the appropriate bibliographic references
and permissions and, upon the district’s request, provide the school district with documentation of these references and
permissions. Printed evidence of the “public domain” status of documents must also be retained and provided to the district
by students or staff if requested.
c. The absence of a copyright notice may not be interpreted as permission to copy the materials. Only the copyright owner may
provide the permission. The manager of the Web site displaying the material may not be considered a source of permission.
d. The “fair use” rules governing student reports in classrooms are less stringent and permit limited use of graphics and text.
e. Student work may only be published on the Internet if there is written permission from both the parent/guardian and student.
10. Use of Electronic Communication
a. The District’s electronic communication systems, and its constituent software, hardware, and data files, are owned and
controlled by the District. The District provides electronic resources to aid students and staff members in fulfilling their
duties and responsibilities, and as an education tool.
b. The District reserves the right to access and disclose the contents of any account on its system without prior notice or
permission from the account’s user. Unauthorized access by any student or staff member to electronic resources (e.g., e-mail,
chat rooms, and other unauthorized electronic communications) is strictly prohibited.
c. Each person should use the same degree of care in drafting an electronic message as would be put into a written
memorandum or document. Users will be held personally responsible for their content of any and all electronic messages.
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Proof of Residency – Documentation
As proof of student residency, please attach to this affidavit at least one document listed in Category A or at least two
documents listed in Category B. Please indicate with an “X” which documents are attached. You must present these
documents at the school, or have this form notarized in the box at the bottom of this page.
***If you are not the parent or legal guardian of the child, you must also complete the Affidavit of Residency.
Category A – Attach a copy of at least one of the following documents:
_____
Signed lease for my residence showing an occupancy date on or before date of student registration.
_____
Signed real estate contract showing closing date.
_____
A closing statement for the purchase of residence showing a closing date on or before date of student
registration
_____
A home construction contract showing expected completion date.*
_____
An affidavit from the owner of my residence state that I reside at the residence on a full time basis.
Please contact the school for a form.
Category B – Attach a copy of at least two of the following documents:
_____
Driver’s license
_____
Gas or electric bill
_____
Public Aid card
_____
Voter registration card
_____
Home/apartment insurance certificate
_____
Automobile registration from State of Illinois
_____
Other (please describe) ______________________________________________
*Note: Residence status must be determined. Please contact Dr. Julie-Ann Fuchs, Assistant Superintendent for Business at 630-365-5111.
TO BE COMPLETED WHEN PERMANENT RESIDENCY IS ESTABLISHED
I, _________________________________________________, declare that I physically reside at __________________________
____________________________________________________________________, Illinois, and that I have no other residence other than
that listed on this Affidavit. In order to affirm my residency in Kaneland Community School District #302, I have presented certain attached
documents to the district officials. I declare these documents to be true and accurate. I understand that I may be required to submit
additional information to substantiate my residency and the residency of the student named above base upon my responses on the District’s
guidelines for determining residency.
I further declare that I am in compliance with the School Code of Illinois which requires that students attend school in the district in
which they live with their parents or guardians, and that I have received a copy of the District’s residency policy, have read it, and agree to
comply with it.
I hereby swear that the answers to the foregoing questions are true and correct. I understand the misrepresentation or intentional
withholding of facts in relation to a student residency issue may result in criminal and civil legal proceedings, as well as denial of enrollment
or disenrollment and the payment of tuition from the time the student was enrolled.
Signature of Parent/Guardian
Subscribed and sworn to before me this_____ day of __________________, 20_____.
_________________________________________
Signature of Notary Public
Date
AFFIDAVIT CONCERNING STUDENT RESIDENCE
Please answer the following questions completely and accurately. If a question is not applicable, please indicate this by
inserting “N/A” in the space provided. Note that this affidavit must be signed and notarized before it is submitted.
Section 1 – General Information – Everyone must complete 1-8
1. Name of Student:___________________________________________________________
2. Address where student presently lives: ________________________________________________________
3. New address within district #302:______________________________________________________________
4. Name of mother:____________________________________________________________
5. Where does mother live? _____________________________________________________
6. Name of father: _____________________________________________________________
7. Where does father live? ______________________________________________________
8. Are the parents divorced? ____________________________________________________
If parents are divorced, please complete 9, 10, and 11
9. Who has legal custody of the student? __________________________________________
10. What is the date of the divorce decree? _________________________________________
11. A certified copy of the divorce decree and any amendments must be furnished.
If student is not living with a parent, complete 12 – 28
12. Name of person(s) with whom the student lives:_________________________________________________
13. Relationship of said person(s) to the student:______________________________________
14. Why is the student living with said person(s)? ____________________________________________________________
15. On what date did the student move in with this person(s)? ___________________________
16. Does the person(s) with whom the student is staying have authority to discipline the student? Yes  No 
17. Is the persons(s) with whom the student stays paid any money for care of the student? Yes 
No 
18. For how long is the arrangement with the person(s) with whom the student is staying? ____________________________
19. Has the person(s) with whom the student lives become legal guardian of the student? Yes 
No 
20. If the answer is yes, attach a copy of the guardianship order.
21. Why was the guardian ship secured? ____________________________ ____________________________________
22. Where did the student reside during the previous summer? _______________________________________________
23. Do you pay any money to support the student? Yes  No 
24. Who is authorized to receive report cards? _______________________________________
25. Who would attend parent conferences at the school? _______________________________
26. Who would receive notification in case of student discipline, suspension or expulsion?___________________________
27. On Saturdays and Sundays, where does the student stay? __________________________
28. Where did the student attend school last year? ____________________________________
29. List the names and ages of any siblings, where they live and where they attend school:
Rev. 2/09
Donations may be made with a credit card at our webstore http://kaneland.revtrak.net/tek9.asp
KANELAND COMMUNITY UNIT SCHOOL DISTRICT #302
MEDICATION AUTHORIZATION FORM
For this student to receive medication during the school hours or to carry asthma medication on school grounds or for schoolsponsored activities, this form must be fully completed by the prescribing physician and an authorizing parent or legal guardian.
STUDENT NAME:___________________________________ BIRTHDATE:____________
GRADE:________ TEACHER:__________________________________________________
MEDICATION/HEALTH CARE TREATMENT:_____________________________________
DATE OF THIS ORDER:_________________
DISCONTINUATION DATE:___________
POSSIBLE SIDE EFFECTS:______________________________________________________
DOSAGE AND TIME TO BE GIVEN:______________________________________________
INTENDED EFFECTS OF THIS MEDICATION:_____________________________________
_____I give permission for self-administration of an asthma inhaler. _____I give permission for self-administration of an Epi-Pen.
Must this medication be administered during the day in order to allow the child to attend school or to address the student's
condition?_______
________________________________
Signature of Physician
____________________
Physician's Phone Number
_________________
Date
PARENT AUTHORIZATION
Asthma Medication: I agree with the information provided above by my child's physician regarding asthma medication. I also give
permission for my child to possess and to self-administer on an "as needed" basis said asthma medication when my child is attending
school, is under the supervision of school personnel, is at school-sponsored activities, or is on school property outside of regular school
hours and regular school activities.
I herewith acknowledge that I am primarily responsible for administering medication to my child. However, in the event that I am
unable to do so or in the event of a medical emergency, I hereby authorize Kaneland School District and its employees and agents, on
my behalf and stead, to administer or to attempt to administer to my child lawfully prescribed medication in the manner described
above. I further acknowledge and agree that I waive any claims I might have against Kaneland School District and its employees and
agents arising out of the administration or attempted administration of medication to my child. I further agree to indemnify and hold
harmless Kaneland School District and its employees and agents, either jointly or severally, against any claims arising out of the
administration or attempted administration of medication to my child. If my child is authorized to self-administer asthma medication, I
acknowledge and agree that Kaneland School District and its employees and agents are to incur no liability, except for willful and
wanton conduct, as a result of any injury arising from the self-administration of medication by my child. I further agree to indemnify
and hold harmless Kaneland School District and its employees and agents, either jointly or severally, against any claims, except a
claim based on willful and wanton conduct, arising out of the self-administration of medication by my child.
I give the school nurse permission to be in contact with the prescribing physician with regards to the above medication order and the
response my child has to the prescribed medication.
______________________________
Parent's/Guardian Signature
___________________
Phone Number
_________________
Date
Kaneland John Stewart
630/365-0651 (FAX)
Kaneland McDole
630/897-3229 (FAX)
Kaneland John Shields
630/466-5320 (FAX)
Kaneland Middle School 630/466-4700 (FAX)
Kaneland Blackberry Creek
630/365-3905 (FAX)
Kaneland High School
630/365-5124 (Nurse FAX)
KANELAND COMMUNITY UNIT SCHOOL DISTRICT #302
A policy for administering medication to children while at school has been established following the guidelines
from the Illinois Department of Human Services and the Illinois State Board of Education. The strict adherence
of this policy is imperative for the safety and well-being of students and staff.
PLEASE FOLLOW THESE PROCEDURES:
1. All medication needed by the pupil during the day will be administered under the supervision of a school
nurse.
2. The parent AND physician must complete the Medication Authorization form for both prescription and
non-prescription medication except inhalers. This includes over the counter pain medication, cold or
allergy medicine, etc. Inhalers with the doctor’s order written into the pharmacy label are acceptable
with the parent signature on the Medication Authorization form.
3. Medication forms need to be renewed annually.
4. All medication will be kept in the office. Students are not to have medication in their possession, unless
written permission from the doctor.
5. All medication must be brought to school by a responsible adult.
6. Medication will be disposed of after the school year, if left at school.
7. If the medication dosage or time is changed, the parent and the doctor must submit in writing these
changes to the nurse.
8. The primary responsibility for medication rests with the parent. We will only administer medication
necessary to sustain a student during the school day.
9. Medication will be accepted in the original pharmacy container. Orders on the prescription container
must exactly coincide with the order as written by the physician.
10. If a student requires emergency medication for food or insect allergy, please have your physician
complete the Consent Form for Medication Authorization. The parent must supply the appropriate
medication.
11. The parent must administer the initial dosage of medication at home in order to observe for side effects.
12. The school district and its employees shall incur no liability except for willful and wanton conduct, as a
result of any injury arising from the self-administration of medication by a pupil.
Student Health Services
Revised 11-29-10
Policy for Administering Medication to Children While at School
This policy has been established following the guidelines from the Illinois Department of Human Services and the
Illinois State Board of Education. The strict adherence of this policy is imperative for the safety and well-being of
students and staff.
PLEASE FOLLOW THESE PROCEDURES:
1. All medication needed by the pupil during the day will be administered under the supervision of a school nurse.
2. The parent AND physician must complete the Medication Authorization form for both prescription and nonprescription medication. This includes pain medication, inhalers, throat lozenges, etc.
3. Medication forms need to be renewed annually.
4. All medication will be kept in the office. Students are not to have medication in their possession, unless written
permission from the doctor.
5. All medication must be brought to school by a responsible adult.
6. Medication left at school will be disposed of after the school year ends.
7. If the medication dosage or time is changed, the parent and the doctor must submit in writing these changes to
the nurse.
8. The primary responsibility for medication rests with the parent. We will only administer medication necessary to
sustain a student during the school day.
9. Medication will be accepted in the original pharmacy container. Orders on the prescription container must
exactly coincide with the order as written by the physician.
10. If a student requires emergency medication for food or insect allergy, please have your physician complete
the Consent Form for Medication Authorization. The parent must supply the appropriate medication.
11. The parent must administer the initial dosage of medication at home in order to observe for side effects.
12. The school district and its employees shall incur no liability except for willful and wanton conduct, as a result
of any injury arising from the self-administration of medication by a pupil.
Student Health Services
Illinois Department of Public Health
PROOF OF SCHOOL DENTAL EXAMINATION FORM
To be completed by the parent (please print):
Student’s Name:
Address:
Last
Street
First
Middle
City
Birth Date:
ZIP Code
Name of School:
Grade Level:
Parent or Guardian:
Address (of parent/guardian):
/
Telephone:
Gender:
£ Male
(Month/Day/Year)
/
£ Female
To be completed by dentist:
Oral Health Status (check all that apply)
£ Yes £ No Dental Sealants Present
£ Yes £ No Caries Experience / Restoration History —
A filling (temporary/permanent) OR a tooth that is missing because it was
extracted as a result of caries OR missing permanent 1st molars.
£ Yes £ No Untreated Caries —
At least 1/2 mm of tooth structure loss at the enamel surface. Brown to dark-brown coloration of the
walls of the lesion. These criteria apply to pit and fissure cavitated lesions as well as those on smooth tooth surfaces. If retained
root, assume that the whole tooth was destroyed by caries. Broken or chipped teeth, plus teeth with temporary fillings, are considered sound unless a cavitated lesion is also present.
£ Yes £ No Soft Tissue Pathology
£ Yes £ No Malocclusion
Treatment Needs (check all that apply)
£ Urgent Treatment — abscess, nerve exposure, advanced disease state, signs or symptoms that include pain, infection, or swelling
£ Restorative Care —
amalgams, composites, crowns, etc.
£ Preventive Care — sealants, fluoride treatment, prophylaxis
£ Other —
periodontal, orthodontic
Please note____________________________________________________________________________________
Signature of Dentist _________________________________________
Date ____________________________
Address ___________________________________________________
Telephone _______________________
Street
City
ZIP Code
Illinois Department of Public Health, Division of Oral Health, 535 W. Jefferson St., Springfield, IL 62761
217-785-4899 • TTY (hearing impaired use only) 800-547-0466 • www.idph.state.il.us
Printed by Authority of the State of Illinois
P.O.#346085
5M
10/05

John Stewart Elementary
817 Prairie Valley Street
Elburn, IL 60119
Phone (630) 365-8170
Fax (630) 365-0651

John Shields Elementary
85 Main Street
Sugar Grove, IL 60554
Phone (630) 466-8500
Fax (630) 466-5320

Blackberry Creek Elementary
1122 S. Anderson Road
Elburn, IL 60119
Phone (630) 365-1122
Fax (630) 365-3905

McDole Elementary School
2901 Foxmoor Drive
Montgomery, IL 60538
Phone (630) 897-1961
Fax (630) 897-3229
Dear Parent/Guardian;
In an effort to provide your child with the best health care at Kaneland, we ask that you notify
us of any health concerns. Conditions such as asthma, allergies, seizure disorders, diabetes, or
heart conditions can affect school performance. If your child has an allergy, please be specific
as to what kind and how serious it is. If emergency medication is needed, please complete a
Kaneland Medication Authorization form. These are available from the health office or at the
Kaneland District website at www.kaneland.org, click on the health services link.
All information will be added to your child’s health file. Information will be shared with
certified teaching staff only and as necessary to ensure the safety of the student.
Please return this form as soon as possible if your child has a health concern. You may also
contact the school nurse’s office anytime to discuss concerns with the nursing staff.
Student Name: ____________________ Grade: _______ Teacher: ______________________
Health Concerns or Allergies:
State of Illinois
Eye Examination Report
Illinois law requires that proof of an eye examination by an optometrist or physician (such as an ophthalmologist) who provides eye
examinations be submitted to the school no later than October 15 of the year the child is first enrolled or as required by the school for
other children. The examination must be completed within one year prior to the first day of the school year the child enters the Illinois
school system for the first time. The parent of any child who is unable to obtain an examination must submit a waiver form to the school.
Student Name ________________________________________________________________________________________________
Birth Date ____________________
(Last)
(First)
(Middle Initial)
Gender ______ Grade _____
(Month/Day/Year)
Parent or Guardian ____________________________________________________________________________________________
(Last)
(First)
Phone ______________________________
(Area Code)
Address _____________________________________________________________________________________________________
(Number)
(Street)
(City)
County ____________________________________________
Case History
Date of exam ________________
(ZIP Code)
To Be Completed By Examining Doctor
Ocular history:
Normal
or Positive for ___________________________________________________________________
Drug allergies:
NKDA
or Allergic to ____________________________________________________________________
Medical history:
Normal
or Positive for ___________________________________________________________________
Other information _____________________________________________________________________________________________
Examination
Uncorrected visual acuity
Best corrected visual acuity
Distance
Right
20/
20/
Was refraction performed with dilation?
Left
20/
20/
External exam (lids, lashes, cornea, etc.)
Internal exam (vitreous, lens, fundus, etc.)
Pupillary reflex (pupils)
Binocular function (stereopsis)
Accommodation and vergence
Color vision
Glaucoma evaluation
Oculomotor assessment
Other _________________________
Yes
Both
20/
20/
No
Near
Both
20/
20/
Normal
Abnormal
Not Able to Assess
Comments
__________
__________
__________
__________
__________
__________
__________
__________
__________
NOTE: "Not Able to Assess" refers to the inability of the child to complete the test, not the inability of the doctor to provide the test.
Diagnosis
Normal
Myopia
Hyperopia
Astigmatism
Strabismus
Amblyopia
Other _______________________________________________________________________________________________________
Page 1
Continued on back
State of Illinois
Eye Examination Report
Recommendations
1. Corrective lenses: No
Yes, glasses or contacts should be worn for:
Constant wear
Near vision
Far vision
May be removed for physical education
2. Preferential seating recommended:
No
Yes
Comments ________________________________________________________________________________________________
_________________________________________________________________________________________________________
3. Recommend re-examination:
3 months
6 months
Other ____________________________________
12 months
4. _________________________________________________________________________________________________________
5. _________________________________________________________________________________________________________
Print name____________________________________________
Optometrist or physician (such as an ophthalmologist)
who provided the eye examination MD OD DO
Address ____________________________________________
____________________________________________
Phone
License Number_____________________________________
Consent of Parent or Guardian
I agree to release the above information on my child
or ward to appropriate school or health authorities.
(Parent or Guardian’s Signature)
____________________________________________
Signature ____________________________________________
(Date)
Date ___________________
(Source: Amended at 32 Ill. Reg. _________, effective ___________)
Page 2
Printed by Authority of the State of Illinois
6/09
IOCI1271-09
Donations may be made with a credit card at our webstore http://kaneland.revtrak.net/tek9.asp
ELEMENTARY REGISTRATION FORM
2015-2016 FEES
TEXTBOOK/ MATERIALS + TECHNOLOGY = TOTAL PER STUDENT
EARLY CHILDHOOD
KINDERGARTEN
GRADES 1 – 5
$60.00 + $22.00
$75.00 + $27.50
$130.00 + $55.00
= $ 82.00
= $102.50
= $185.00
Grades 1 – 5
Milk Purchase – Price is per Student
1st Semester $24.00



2nd Semester $25.00
Full Year $48.00 ($1-discount)
If you want to purchase 2 cartons of milk daily just double the fee per child
Full Year price offers a $1.00 discount off individual semester purchases
There will be no refunds for absences. The only refunds will be for withdrawing from Kaneland schools
1. List below the name and grade for the coming school year of student(s) for whom payment is enclosed.
2. Make check payable
via the Kaneland Web Store)
to KANELAND
DISTRICT #302 (If you would prefer to pay by credit card, you can pay online

If you would like to donate to Kaneland Foundation to help support Kaneland students, you can visit the
Kaneland Web store, at www.Kaneland.org, where you will find the Kaneland Foundation Link.
3. Return this form and your check by the due date listed below.
LAST NAME
FIRST NAME
GRADE
2015-2016
Kaneland Foundation Donation
Milk Total
Registration Fee
Total Per
Student
Optional
$10
Total Amount Enclosed
REGISTRATION FEES ARE DUE:
♦ Fees for returning students must be received at the school or postmarked on or before August 18, 2014.
♦ Fees for new students to Kaneland District #302 including Kindergarten are due on or before their first
day of attendance.
MILK:
♦ Payment for 1st semester/Full Year is due by August 19. After this date milk orders will not be accepted
♦ Second semester milk fees will be due Friday, January 15, 2016. Forms will be posted in Konnect.
Registration fees are charged to all students except those specifically exempted by law or unable to pay due to emergency circumstances.
However, unless exempted by law, all fees are to be collected. Individuals in need of alternative payment schedules of a fee waiver should
contact the building principal secretary. If necessary, the collection process will involve the referral of unpaid fees to a collection agency.
Blackberry Creek
1122 S. Anderson Rd.
Elburn, IL 60119
630-365-1122
Rev 1/15
John Shields
85 Main St.
Sugar Grove, IL 60554
630-466-8500
John Stewart
817 Prairie Valley St.
Elburn, IL 60119
630-365-8170
McDole School
2901 Foxmoor Dr.
Montgomery, IL 60538
630-897-1961
Attendance Guidelines for Parent and Guardians of Students in
Kindergarten-12th Grades
Notification of Student Absence
In the event of a student absence, please follow these procedures:
1. Prior to 10 A.M. each day, please call the school’s office/attendance line to report your student’s
absence. We urge all parents to call in before that time. If you are unable to call before 10 A.M.
please call the school as soon as possible. The voice mail for attendance is available twenty-four
hours a day.
2. The parent or legal guardian is the only authorized person to inform the school of a student’s
absence.
3. If no call is received, the attendance secretary will attempt to contact a parent or legal guardians
at home or work. If the attendance secretary is unable to reach a parent or legal guardian, the
student should bring a note signed by a parent the next morning.
Note: Any absence (excused or unexcused, half day or full) counts against attendance. This includes
awards for perfect attendance.
Excused and Unexcused Absences/Tardiness
Student absences and tardiness are marked as follows:
Excused
EA-Excused Absence: A student may be absent from school because of illness, family emergency,
situation beyond the control of the student or such other circumstance which cause reasonable concern
to the parent for the safety or health of the student.
MA-Medical Absence: If a student is absent more than five consecutive days due to illness (such as
chicken pox), a letter from a physician should be submitted to the school.
IF-Illness with Fever: For a student sent home or who has called in sick with a fever of 100o or higher.
Children need to be fever free without the use of fever reducing medication for 24 hours before
returning to school.
PA-Prearranged Absence: Vacations, while not encouraged, must be pre-arranged. Additionally, any
time a student will knowingly be absent from school, the student and parent must complete the preexcused absence form, which can be obtained in the school office.
Updated 3/2013
Page 1
Attendance Guidelines for Parent and Guardians of Students in
Kindergarten-12th Grades
PA-Prearranged Absence cont.
A. Prearranged Absence Request should be filled out for any of the following reasons:
 Medical appointments that will keep the student out of school all day
 Family vacation
 Business trip with parents
 Appearance in court
 College visitation
 Funeral
 Religious Holiday
If students are to be absent from school for any of the above stated reasons, the following procedures
should be done, or the absence will be considered unexcused:
1. Obtain a Pre-Excused Absence Form from the attendance secretary in the office.
2. It is the student’s responsibility to ensure that all class work is completed as per each teacher’s
instructions. Parents should contact their student’s teacher to request homework for any
Prearranged Absence.
3. Parents are urged to encourage their student to complete all assignments prior to returning to
school.
4. It is the right of the school to consider any of the above absences unexcused, if a student is
repeatedly pulled out of school for trips or vacations.
ET-Excused Tardy: Only tardiness involving serious problems or emergencies is excused.
Unexcused
UA-Unexcused Absence: Reasons for unexcused absences shall include truancy, failure to have proper
verification to explain an absence and any unauthorized departure from the building. A student would
be considered unexcused if the school was not contacted by the parent regarding the student’s absence
and an attempt to contact the parent was unsuccessful.
UT-Unexcused Tardy: Tardiness is considered unacceptable behavior. Oversleeping, family errands and
missing the bus are not acceptable reasons for being tardy.
Updated 3/2013
Page 2
Attendance Guidelines for Parent and Guardians of Students in
Kindergarten-12th Grades
Partial Day Attendance (Arriving Late/Leaving Early)
A student who arrives late to school must report to the office to sign in and receive a pass back to class.
The student should bring a note upon arrival, or the parent/guardian must call. The determination of
whether the absence or tardy is considered excused or unexcused is based on the guidelines above.
If a student needs to leave school early, he or she must bring a note from his or her parent/guardian
stating the reason to the office prior to the beginning of the school day. This note must state the reason
for early dismissal and phone number of the parent/guardian so the office can confirm the information.
Students must wait in the office to be signed out by their parents.
Upon returning to school the same day, the student must report to the Attendance Office before
returning to class. A student returning to school from medical appointments must bring documentation
from the medical office confirming his or her appointment to the Attendance Office.
Time frame for determining full/half day absences
The following guidelines will be used in determining absences and tardiness as per Illinois School Law
(105 ILCS 5/18-8.05):
1. For grades 2-12, if the student is here 150-300 minutes they are considered a half day present.
If they are here 300 + minutes, it is a full day present; less than 150 minutes it is a full day
absent.
2. First grade and full day Kindergarten should be in attendance 240 + minutes for a full day
present. If they attend between 120-239 minutes, it is a half day present. Less than 120
minutes is a full day absent.
Attendance and After School Activities
Participation in school sponsored activities on school days, outside the regular school day, requires
attendance in school at least half of the school day. Students who are sent home from school due to
illness will not be allowed to participate in school sponsored after-school activities. Examples of
activities include, but are not limited to, After Class Enrichment (ACE)/PARTNERS and musical programs,
athletics and band.
Updated 3/2013
Page 3
KANELAND COMMUNITY UNIT SCHOOL DISTRICT #302
2015-2016 SCHOOL YEAR CALENDAR
AUGUST ‘15
17
18
19
Teacher Institute
Teacher Institute
First Day of School
S
M
T
W
SEPTEMBER ‘15
Th
F
S
S
1
Columbus Day
End Quarter 1
Winter Break
Th
F
S
2
3
4
5
8
9
10 11 12
3
4
5
6
7
8
6
10
11
12
13
14
15
13 14 15 16 17 18 19
16
17
18
20
21
22
20 21 22 23 24 25 26
23
24
25
27
28
29
27 28 29 30
30
31
S
M
T
W
4
5
6
7
11 12
13
18
19
20
25
26
27
S
M
NOVEMBER ‘15
Th
F
S
S
M
1
2
8
9
3
1
10
8
14
15
16
17
21
22
23
24
15 16 17 18 19 20 21
1
22 23 24 25 26 27 28
28
29
30
31
29 30
DECEMBER ‘15
21-31
W
9
26
6
7
13
7
T
1
2
OCTOBER ‘15
12
23
M
T
W
Th
F
S
2
3
4
5
6
7
9
10 11 12 13 14
7
Labor Day
5-6
Parent/Teacher
Conference Days
23 Teacher Institute
24 School Improvement
Day
25-27 Thanksgiving Break
JANUARY ‘16
T
W
Th
F
S
1
2
3
4
5
8
9
10
11
12
3
10 11 12 13 14 15 16
1
17 18 19 20 21 22 23
14
15
16
17
18
19
20 21
22
23
24
25
26
27 28
29
30 31
S
M
T
W
Th
F
1
4
5
6
7
8
S
2
9
1
15
18
Winter Break
End Quarter 2
M.L. King Jr. Day
24 25 26 27 28 29 30
31
FEBRUARY ‘16
S
15
Presidents’ Day
M
T
W
Th
F
MARCH ‘16
S
S
M
7
1
Spring Break
Th
F
1
8
S
2
3
4
9
10 11 12
5
1
2
3
4
5
6
8
9
10
11
12
13
6
14
15
16
17
18
19
20
13 14 15 16 17 18 19
21 22
23
24
25
26
27
20 21 22 23 24 25 26
28
29
S
M
4
Kane County Institute
Day
24
End Quarter 3
25
In-Service Day
27
Easter Sunday
28-31 Spring Break
27 28 29 30 31
T
W
Th
MAY ‘16
F
S
S
M
T
W
Th
F
S
1
2
1
2
3
4
5
6
7
9
10 11 12 13 14
3
4
5
6
7
8
9
8
10
11
12
13
14
15
16
15 16 17 18 19 20 21
17
18
19
20
21
22
23
22 23 24 25 26 27 28
24
25
26
27
28
29
30
29 30
S
M
T
F
S
5
6
7
12
13
19
26
JUNE ‘16
Emergency Days
Semester 1 – 89 days
Semester 2 – 88 days
Adopted: 10-27-14
Amended: 02-09-15
Amended: 03-23-15
W
7
APRIL ‘16
1
T
31
JULY ‘16
W
Th
S
M
T
W
Th
1
2
3
4
8
9
10
14
15
16
20
21
22
23
27
28
29
30
F
11
3
4
5
6
7
17
18
10 11 12 13 14 15 16
24
25
17 18 19 20 21 22 23
1
8
S
2
9
24 25 26 27 28 29 30
31
24
Last day of student
attendance if no
snow days are used
30
Memorial Day
25, 26, 27 & 31 Emergency
Days
1st Quarter – 46 days
2nd Quarter – 43 days
3rd Quarter – 46 days
4th Quarter – 42 days
Total – 177 days
1 hour early dismissal on
January 14, 15and
May 23, 24
03-23-15