Student Information
STUDENT A:
1. Name of Student: __________________________________________________
Last First Middle
2. Nickname: __________________ Grade Enrolling: ___________ Age: ______
3. Male___ Female___ Known Allergies: _________________________________
STUDENT B:
4. Name of Student: __________________________________________________
Last First Middle
5. Nickname: __________________ Grade Enrolling: ___________ Age: ______
6. Male___ Female___ Known Allergies: _________________________________
Emergency Information
7. Mother’s Phone Contact Numbers:
Cell: ________________ Work: ________________ Home:_______________
8. Father’s Phone Contact Numbers:
Cell: ________________ Work: ________________ Home:_______________
Persons to contact in case of emergency if Parent or Guardian cannot be reached:
a. Name: ________________________ Phone Number: _____________
b. Name: ________________________ Phone Number: _____________
Persons, other than above, who have permission to remove the child from school:
c. Name: ________________________ Relationship: _______________
d. Name: ________________________ Relationship: _______________
e. Name: ________________________ Relationship: _______________
f. Name: ________________________ Relationship: _______________
STUDENT A: Name of Student: __________________________________________
Last First Middle
9. School Year : _______________ Grade at Transferring School: ___________
a) If a transfer: Name of School __________________________________
b) School’s Mailing Address: _____________________________________
c) School’s City, State, Zip: ______________________________________
10. Date of Birth __________________ Social Security # _____________________
11. Student’s Physician: _____________________________________
12. Physician’s Address: ____________________________________________
13. Phone#: _________________ Preferred Hospital: _____________________
14. Does the applicant have any health problems? ________________________
15. Known allergies? _______________________________________________
16. Taking any medications? _________________________________________
STUDENT B: Name of Student: __________________________________________
Last First Middle
17. School Year : _______________ Grade at Transferring School: ___________
a) If a transfer: Name of School __________________________________
b) School’s Mailing Address: _____________________________________
c) School’s City, State, Zip: ______________________________________
18. Date of Birth __________________ Social Security # _____________________
19. Student’s Physician: _____________________________________
20. Physician’s Address: ____________________________________________
21. Phone#: _________________ Preferred Hospital: _____________________
22. Does the applicant have any health problems? ________________________
23. Known allergies? _______________________________________________
24. Taking any medications? _________________________________________
25. Home Street Address: _____________________________________________
26. City, State, Zip: ___________________________________________________
27. Mother’s Name: _________________________ SSN#: ____________________
28. Address: _________________________________________________________
29. Occupation: ______________________________________________________
30. Employer and Address: _____________________________________________
31. Father’s Name: _________________________ SSN#: ____________________
32. Address: _________________________________________________________
33. Occupation: ______________________________________________________
34. Employer and Address: _____________________________________________
35. Email Address: _________________________________________________
*school communications are sent via email. Please provide the email address you access frequently.
36. Legal Custodian: _________________________________________________
37. Address: _______________________________________________________