Swink School District Enrollment Form NS- KR

Alternate Household

Non Custodial
Does an Alternate Household exist?*

YesNo
Alternate Parent Name

First NameLast Name
Relationship

fathermotherstepparentgrandparentGuardian
Alternate Parent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Number

Area CodePhone Number
Cell Number

Area CodePhone Number
Home Email
example@example.com
Work Email
example@example.com
Home Phone Number

Area CodePhone Number
If you need additional person(s) added please add them in this area

Emergency contacts

Enter additional contacts not listed above

LIst

	Name	Relationship	Home Phone	Cell Phone
1
2
3
4
5

Emergency Medical Information
Physician*

First NameLast Name
Phone Number*

Area CodePhone Number
Medical Notes
Hospital

Completed by*

First NameLast Name
Signature *

Clear
Date

MonthDayYear
Date
Should be Empty: