Student’s Full Name ________________________________________________________________
(spell
out each name) LAST FIRST MIDDLE
What name is child
called at home? _______________________
Birthday
________________ Sex ________ Race __________ SS # ________________________
Do you have
Immunization Records? Yes No
Custody: (1) Both Parents (2) Mother (3) Father
(4) Other _____________________________
Morning Bus #
_______ Afternoon Bus # ______ Miles Ridden on Bus one way ____________
Parent’s Names and
Addresses: Mother
____________________________Phone ____________
(911 Home Addresses ____________________________________________________
____________________________________________________
Father
_____________________________Phone____________
____________________________________________________
____________________________________________________
Work place and phone
number: Mother______________________________________________ Father
______________________________________________
Head
Start? Yes No Did child attend
pre-school? _______ Where? ______________________
Persons to call when
parents cannot be reached:
______________________________________Phone
_______________ Relation _______________
______________________________________Phone
_______________ Relation _______________
If you cannot be reached and our child should need
emergency treatment by a physician or hospital attendant, do you give your
permission for him/her to receive medical attention? _____________
Child’s Physician
_______________________________Phone _______________________
In case of early
dismissal of school for snow, floods, etc., what procedures should your child follow? Ride bus home
_________ Other instructions
__________________________________
Please explain any
medical conditions of which your child’s teacher should be aware: _________
List those who have
legal authority to pick up your child from school: ______________________
Who may NOT pick up
your child? ____________________________________________________
Please give specific
directions to child’s home: ___________________________________________
Other children in
school:
Name
__________________________________________Age _____________ Next Yr's Grade ____________
Name
__________________________________________ Age _____________ Next Yr's Grade ___________
Name
__________________________________________ Age _____________ Next Yr's Grade ___________
Other children NOT in school:
Name ____________________________________________ Age ____________________
Name ____________________________________________ Age ____________________
Home Language Survey:
1. What is the first language your child
learned to speak?
_______ English Other ________________
2. What language does your child speak
most often outside of school?
_______ English Other _________________
3. What language do people usually speak
in your child’s home?
________ English Other __________________