Student Name: __________________________________ Date of Birth:_________________

Name of Parent(s) or Guardian(s): ________________________________________________

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Home Address: __________________________________________________________________
Below, please indicate which number is the best way to contact you if needed
Home Phone: _______________________
Moms Work: ________________________

Moms Cell: _______________________

Dads Work: _________________________

Dads Cell: ________________________

Emergency Contact:
Emergency contact name and relation to student: _____________________________
Phone Number: ______________________
Are any other languages other than English spoken at home? ______________________
How will your child get to and from school each day? ______________________________
*If there are any changes to be made in transportation, please send a note to notify*
Are there any concerns you have about your child I should know about?
(Medically, socially, academically): __________________________ __________________
______________________________________________________________________________
______________________________________________________________________________
List anything your child may have an allergic reaction to: _______________________
________________________________________________________________________________
Please identify your childs strengths and weaknesses in subject areas: _____________
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List two goals you would like to set for your child: _______________________________

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