CONFIDENTIAL FAMILY / STUDENT INFORMATION

CONFIDENTIAL FAMILY / STUDENT INFORMATION
Form 5124.2
Student’s (Legal) Name*

First NameLast Name
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Student's Birth Date*

MonthDayYear
Date
CHILD’S PARENTS:
Father's Full Name

First NameLast Name
Mother's Full Name

First NameLast Name
Guardians
Legal Custodians
Please check all that apply

DivorcedSeparatedRemarriedWidowedUnmarried
Individual with whom the child primarily lives
Check Relationship

FatherMotherOther
If you answered Other, State Relationship:
Does the parent with whom the child does not live have any court restrictions placed on his/her parental rights?

YesNo
If Yes, what are the restrictions?
If the child lives with the remarried parent, is the parent’s spouse the adoptive parent?

YesNo
*please substantiate these items by attaching a copy of the court order/divorce decree to this form.
Parent/legal guardian*
By entering my full name, I attest that this constitutes my legal electronic signature on this form.
Signature*

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Date*

MonthDayYear
Date
Should be Empty:

CHILD’S PARENTS: