HTML Preview Student Information Sheet page number 1.
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Student Information Sheet 2016-2017
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Student
Name:
(First) (Last)
Date of Birth: Female
Male
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Parent
#1:
(First) (Last)
Street
Address:
City:
Zip:
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Home
phone
#:
Cell
#:
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Parent
Email
Address:
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Parent’s
Workplace:
Parent’s
Profession:
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Work #: Does the student live with you? Yes
No
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Parent
#2:
(First) (Last)
Street
Address:
City:
Zip:
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Home
phone
#:
Cell
#:
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Parent’s
Email
Address:
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Parent’s
Workplace:
Parent’s
Profession:
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Work #: Does the student live with you? Yes
No
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Are
there
any
other
adults
that
the
student
resides
with?
If
so
who?
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Emergency
Name
&
Phone
#:
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Please note: Parents may not be the Emergency Contact, this number is used in the event that
we
cannot reach either
pa
r
ent
.
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Primary
Care
Physician:
Phone
#:
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Dentist:
Phone
#:
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Hospital:
Phone
#: