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One Day Enrollment for Exams

Parent/Legal Guardian signature (use mouse to sign)

Name of Parent/Legal Guardian

STUDENT INFORMATION

Middle Initial

ACKNOWLEDGEMENT

Date*

Relationship to Student

Before submitting form, please verify your answers. After pressing SUBMIT FORM, if there are errors, they will be noted in red. Parent or Guardian will be required to submit proof of residency.

Student's Home Address (Appt/Unit Number)

City

State

Zip

Date of Exam*

Exam*

Time*

Exam Location*

Students must verify with their schools the exact times that they are to report for their State examinations.

Date of Birth*

Last Name*

First Name*

400 Lake Street • P.O. Box 549 • Ithaca, New York • 14851-0549

ITHACA CITY SCHOOL DISTRICT

OFFICE USE ONLY

IEP/504 ENL

Student ID

Current immunization records must be on file with ICSD for your child to take Regents exams.