First Name of Student:

Last Name of Student:

Middle Name of Student:

Grade:

Street Address:

City:

State:

Zip:

Home Phone:

Place of Birth:

Student Resides with:

Date of Birth:

Age:

Gender:

Ethnic Background:

Father

Name:

Workplace:

Work Phone:

Mother

Name:

Workplace:

Work Phone:

Legal Guardian

Name:

Workplace:

Work Phone:

Emergency Contact

Name:

Relationship to Student:

Phone Number:

Are there any medical concerns we need to know about?

What was the last school you attended?

Complete Name of School:

Street Address:

City:

State:

Zip:

Are you an out of district student?

If yes, what district do you reside in?

I have received a copy of the student handbook?