STUDENT INFORMATION SHEET

STUDENT NAME______________/_______________/______________

Last First Middle Name

ADDRESS___________________________________________________

____/____/____ __________________ __________ ______________

Date of Birth Home Phone/ Emergency Phone No./Name of Person

_________________________________

2^nd Emergency Phone No./Name of person

DATE ENROLLED____/____/____

SOCIAL SECURITY NUMBER_____/_____/_____

HOMEROOM TEACHER___________________________GRADE____

BUS DRIVERS NAME_________________________BUS#___________

SCHOOL LAST

ATTENDED__________________________________________________

___________________/________/_________________/________/_______

Street P.O. Box City State Zip Code

PARENT INFORMATION

FATHER’S NAME ___________________________________________

Last First Middle Initial

MOTHER’S NAME___________________________________________

Last First Middle Initial

Parents Marital Status: (Circle One) SINGLE MARRIED DIVORCED

IF SINGLE OR DIVORCED WHO HAS CUSTODY?_____________________________________________________________________________________

______________________________________________________ ______/______/______

PARENT OR GUARDIAN SIGNATURE DATE