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Student Information Form

STUDENT INFORMATION:

Student Name*

Answer required for "Student Name"

Grade

Answer required for "Grade"

Date of Birth*

Answer required for "Date of Birth"

Street Address*

Answer required for "Street Address"

City*

Answer required for "City"

Zip Code / Postal Code*

Answer required for "Zip Code / Postal Code"

MOTHER/GUARDIAN INFORMATION:

Name*

Answer required for "Name"

Phone*

Number Required

Email*

Answer required for "Email"

Street Address*

Answer required for "Street Address"

City*

Answer required for "City"

Zip/Postal*

Answer required for "Zip/Postal"

Employer and Title

Answer required for "Employer and Title"

Work Address

Answer required for "Work Address"

Work Phone

Answer required for "Work Phone"

FATHER/GUARDIAN INFORMATION:

Name

Answer required for "Name"

Phone*

Number Required

Email*

Answer required for "Email"

Street Address*

Answer required for "Street Address"

City*

Answer required for "City"

Zip/Postal*

Answer required for "Zip/Postal"

Employer and Title

Answer required for "Employer and Title"

Work Address

Answer required for "Work Address"

Work Phone

Number Required

EMERGENCY CONTACT INFORMATION:

(Information to be used if the school is unable to reach the parents.)

Name #1*

Answer required for "Name #1"

Relationship to student*

Answer required for "Relationship to student"

Address

Answer required for "Address"

Phone*

Number Required

Name #2*

Answer required for "Name #2"

Relationship to student*

Answer required for "Relationship to student"

Address

Answer required for "Address"

Phone*

Number Required

MEDICAL INFORMATION:

(Information to be used if the school is unable to reach the parents.)

Doctor Name

Answer required for "Doctor Name"

Phone

Number Required

Dentist Name

Answer required for "Dentist Name"

Phone

Number Required

Health and Accident Insurance/Address

Answer required for "Health and Accident Insurance/Address"

Policy or Group Number

Answer required for "Policy or Group Number"

I/WE HEREBY AUTHORIZE THE SCHOOL TO ADMINISTER THE FOLLOWING MEDICATION(S) IF DEEMED NECESSARY (please check the medication(s) that may be given to your child.)*

Answer required for "I/WE HEREBY AUTHORIZE THE SCHOOL TO ADMINISTER THE FOLLOWING MEDICATION(S) IF DEEMED NECESSARY (please check the medication(s) that may be given to your child.)"

Tylenol

Motrin

Advil

Other

NONE - Call parents first.

Please list any allergies or medical conditions that the school should be aware of (examples include allergies, asthma, diabetes, etc).*

Answer required for "Please list any allergies or medical conditions that the school should be aware of (examples include allergies, asthma, diabetes, etc)."

We would like to be added to the Pesticide Notification Directory. *

Answer required for "We would like to be added to the Pesticide Notification Directory. "

Yes, please notify us.

FAMILY DIRECTORY LISTING:

Student names, grades, names of parents, addresses, cell phone numbers, and emails will be listed in the family directory, which will be distributed to all FRA families. If you do not wish to have your cell numbers and emails published in the directory, please indicate below.

Please list the cell phone numbers and email addresses.

Answer required for "Please list the cell phone numbers and email addresses."

Yes

Signature*

Signature Required

Confirmation Email

Confirmation Email *

Answer required for "Confirmation Email"