Student Info

Student: ______________________ Nickname: ______________ D.O.B:___/___/___

Can be:  Photographed?  Videotaped?  Use the Internet?
To School:  Car  Bus  Bike  Walk  Other: ____________________
From School:  Car  Bus  Bike  Walk  Other: __________________

Medical Conditions & Special Needs: _______________________________________

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Allergies & Dietary Restrictions: ____________________________________________
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Parent/guardian/s: ______________________________________________________
 Lives with full time  Lives with part time
Phone 1: ___________________________ Phone 2: ___________________________
Mobile: _______________________ Email: ___________________________________
Preferred: _________________ Best Time to Contact: _________________________

Emergency Contact 1: ________________________ Relation: ___________________

Phone: ____________________________ Mobile: ____________________________
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Emergency Contact 2: ________________________ Relation: ___________________

Phone: ____________________________ Mobile: ____________________________
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Other schools they have attended: _________________________________________

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Sibling: ____________________________ Sibling: ____________________________

Age: _____ Grade: _____ Age: _____ Grade: _____
School: ____________________________ School: ____________________________

Sibling: ____________________________ Sibling: ____________________________

Age: _____ Grade: _____ Age: _____ Grade: _____
School: ____________________________ School: ____________________________

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 Student
StudentBirthdays
Info

Problem Areas: __________________________________________________________

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Their Goals:
1. _____________________________________________________________________
2. _____________________________________________________________________
3. _____________________________________________________________________

My Goals for them:

1. _____________________________________________________________________
2. _____________________________________________________________________
3. _____________________________________________________________________

Goals Results
Subject Goal Quarter 1 Quarter 2 Quarter 3 Quarter 4 Overall

Interests: _______________________________________________________________
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Extracurricular/Club Involvement: __________________________________________
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Notes: __________________________________________________________________
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