Student Information

Student Information
Student Name

First Name Last Name
Date of Birth

Month Day Year
Date
Grade / Teacher
Mother's Name blanks Phone blank Work Phone
Father's Name blanks Phone blank Work Phone Street Address Address Line 2 City State Zip
Student lives with

Both parents Mother Father Other

Adults permitted to check out student or call in an emergency

Name

Relationship

Phone

Pickup Person #1

Pickup Person #2

Pickup Person #3

Transportation

Select

Bus Number or Day Care Provider (if applicable)

School Bus and Number

CJH More After School Tuition Program

Other Day Care

Car Rider

CJ Hicks Elementary School Bus Transportation Sheet for Bus ______

This information must be completed ONLY if the student
is riding the school bus.

Student Name

Grade

Teacher

Start Date for Riding Bus

Home Address

Bus Stop

2021-RCPS Clinic Information Form for ALL CJ Hicks Students