Student Registration
301 South Swift Road • Addison, Illinois 60101
630-620-8770 • Fax: 630-691-7592 		Select Home School:
Student I.D.
Student's Last Name:

 Student's First Name:
 Sex:

Pathway to Engineering (PLTW)


Select First Program Choice


Select Second Program Choice


Select Third Program Choice
Birth Date
Social Security Number
- -

Home Phone Number
- -


Student's E-Mail Address
Student's House
Number

 Student's Street
Direction
Street Name
City
 State
 Zip Code

Father/Guardian First Name


 Father/Guardian Last Name
Father/Guardian
House Number

 Father/Guardian
Street Direction
Father/Guardian Street Name
City
 State
 Zip Code

Mother/Guardian First Name


 Mother/Guardian Last Name
Mother/Guardian
House Number

 Mother/Guardian
Street Direction
Mother/Guardian Street Name
  
City
 State
 Zip Code
Father/Guardian
Cell Phone
- - 		Father/Guardian
Business Phone / Ext
- - Ext.
Father/Guardian's E-Mail Address
Mother/Guardian
Cell Phone
- - 		Mother/Guardian
Business Phone / Ext
- - Ext.
Mother/Guardian's E-Mail Address
Nondiscrimination Statement: It is the policy of the Technology Center of DuPage not to discriminate in its education programs, activities, or employment policies with regard to race, color, sex, national origin, or handicap.
TO BE COMPLETED BY COUNSELOR (Please check all that apply.)
The State requires the following information for program funding purposes.




State I.D.




 		Year of Graduation


Next Year Grade Level
Counselor's Name:
Counselor's Signature: _____________________________________________
EMERGENCY INFORMATION
Local relative/friend who will be responsible for your student should he/she become ill and you cannot be reached.
Emergency Contact First Name
 Emergency Contact Last Name
Emergency Contact First Name
 Emergency Contact Last Name
Emergency Phone
- -
Emergency Phone
- -
Medications (if none, type "NONE")
 Allergies (if none, type "NONE")
Doctor's First Name
 Doctor's Last Name
 Doctor's Phone
- -