Please print on card stock paper if available.
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Name
_______________________________________________________ D.O.B. _______________ Last First Middle Grade/Teacher
__________________Bus Number: ______Rides bus to: HOME OTHER ___________ Address
____________________________________________Home Phone # __________________
Name
of father/stepfather _________________________________Daytime Phone
#_______________ Name
of mother/stepmother _______________________________Daytime Phone
#_______________
Please
list names of those who might at times be sent by you to check your child out
of school. 1.
______________________________________ 2.
_______________________________________ (May
list additional names on back of card if necessary) Are
there custody concerns involving your child of which we should be aware? YES
_____ NO _________________(DESCRIBE
ON BACK OF THIS CARD) Who
should be contacted first in the event that contact is necessary? ____________________________ Emergency
name and number other than above:
_____________________________________________ Does
your child have any physical and/or medical problems of which we need to be
aware? YES
_____ NO _________________ (DESCRIBE ON BACK OF THIS CARD) |