Student Information

Last Name _____________________ First Name _____________________

Middle Name ___________________ NIckname______________________
Home Phone____________________ Cell Phone _____________________
Emergency Contact____________________________________________
Emergency Number____________________________________________
Birthday ______________________________________ (please include year)
Age________
Parent or Guardian 1_________________________ Relationship __________
Parent or Guardian 2 _________________________ Relationship _________
Parent or Guardian Work Phone _____________________________________
Parent or Guardian E-mail ________________________________________
Do you have access to Internet at home? Yes___No ___
Home Address _______________________________________________
City _________________________ State _____ Zip Code ____________
Allergies/ Medical Concerns______________________________________
What extra-curricular activities does your child participate in? __________________
________________________________________________________
Enrolled Siblings: (Include Teachers) ___________________________________
_______________________________________________________

Transportation:
Bus number________ Daycare Name___________ Walker____ Parent Pick up____
AM_____________________________________________________
PM_____________________________________________________
Is this for the 1st day only? yes___ no____
Additional transportation information_________________________________
_______________________________________________________
_______________________________________________________
Is there anything else I need to know?__________________________________
_______________________________________________________
_______________________________________________________
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2011