7:060-E3 Evidence of Non-Parent’s Custody, Control, and Responsibility of a Student

This form establishes a child’s residency in the School District 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.

Student’s Name:  ________________________________

District Attendance Building:  ____________________________

Name of Individual Completing this Form (Please Print):  __________________________

Relationship to Child:  __________________________

Please check all applicable boxes:

_____  The child lives with me at my residence address, as stated below, and is not living with me solely for the purpose of attending the District’s school.

_____  I have assumed and exercise full legal responsibility for and control of the child regarding daily educational and medical decisions, including responsibility for:

_____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 ____________________________________________________

_____Spends weekends and summers ________________________________

Important Warning: The School District reserves the right to evaluate the evidence presented. Completing this form does not guarantee admission. 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).

Signature of individual completing this form:  ________________________________

Address:  _______________________________________________________________

Telephone:  ___________________________      Date:  ___________________


 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:


_____ The transfer of custody is not solely for the purpose of attending the District’s Schools.

______________________________________________          _____________

Signature of individual completing this form                               Date

Address:  _____________________________________________________________

Telephone:  ________________________


Date Approved:  06/24/2009