Student's Name
*
DOB
*
SS#
Student Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Student Primary Phone Number
-
Area Code
Phone Number
Parent Email Address:
example@example.com
Student's Insurance Company
Group and/or Plan #
Parent/Guardian's Name
*
Parent/Guardian's Name2
Parent Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Active Military
Yes
Parent/Guardian(s)Primary Phone #s
*
Parent/Guardian(s)Work Phone #s
Guardianship?
Student
Parent
Other
Doctor's Name
Phone #
Doctor's Street Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Medicine
Dosage
Time Administered
Name of Medicine
Dosage
Time Administered
List any medical problems the student has (e.g. allergies, diabetes, epilepsy: type of seizures, etc)
Does the student require any other special attention at any time: If so, please explain
Signature of Parent/Guardian
*
Date
/
Month
/
Day
Year
Date
Release of Student - 2 names are REQUIRED
Other than the parent/guardian
Student Name:
#1 Emergency Contact Name:
*
Relationship
*
Phone Number(s)
*
Address:
Street, City, Zip
Authorized Contact Signature
#2 Emergency Contact Name:
*
Relationship
*
Phone Number(s)
*
Phone Number(s)
Address:
Street, City, Zip
AUTHORIZED CONTACT SIGNATURE:
The persons whose signatures appear above may authorize the release of my child from school Parent Signature(s)
Date
/
Month
/
Day
Year
Date
Home Language and McKinney - Vento Survey
Is your child's/ward's native tongue a language other than English?
*
Yes
No
If YES, what language?
Is the primary language used in your child's/ward's home or environment a language other than English?
*
Yes
No
If YES, what language?
Do you live in any of the following situations?
*
Yes
No
If YES, check all that apply:
Shelter - Homeless
Shelter - Domestic Violence
Shelter - Youth
Transitional Housing
Doubled Up living with others due to LOSS OF HOUSING
Doubled Up living with others due to ECONOMIC HARDSHIP
Doubled Up living with others due to PERSONAL CHOICE
Doubled Up living with others due to SAVE MONEY
Hotel/Motel due to LACK OF ALTERNATIVE ADEQUATE ACCOMMODATIONS
Hotel/Motel due to WAITING FOR PERMANENT HOUSING TO BE READY
Hotel/Motel due to CONVENIENCE
Unsheltered - CARS
Unsheltered - PARKS
Unsheltered - CAMPGROUNDS
Unsheltered - TEMPORARY TRAILERs
Unsheltered - ABANDONED BUILDINGS
Unsheltered - SUBSTANDARD HOUSING
Unsheltered - NON-RESIDENTIAL PUBLIC SPACES
Unsheltered - BUS or TRAIN STATIONS
How long do you anticipate living at this location?
Is the student living with someone other than his/her parent or legal guardian?
*
Yes
No
Is the student living in a temporary foster care placement or awaiting foster care?
*
Yes
No
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