Student's Name: 
(Last, First, Middle,  Nickname)
Today's Date: Student's Social Security Number 
Birthdate:    Age:   Sex:   Race:
Grade In School: 
Address: City/State: Zip:

Home Phone:   Student Lives With:
Father's Name: Mother's Name:
Father's Address:                                        Mother's Address:
 
If your child receiving any Special Education Services? Yes No
If yes, please list the service:


List any activities that your child is currently participating in at school, church, or community


AT LEAST TWO Emergency Numbers if unable to contact parents:
Name: Relationship: Phone:
Name: Relationship: Phone:

Allergies: (Please list them all and students reaction to them)


Medicine taken on a regular basis:
Reason: Dose:
Medicine taken on a regular basis:
Reason: Dose:

Health Problems:


In an emergency where would you like your student to be taken for care:
(Name, Address, Phone)


Physician/Care Provider's Name:
Address: City/State: Zip:

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