Breckenridge High School Information
Name
Legal First Name
Legal Middle Name
Legal Student Last Name
Grade
Gender
Male
Female
Birth Certificate on File
Yes
No
School District where student lives
Date of Birth
/
Month
/
Day
Year
Date
Student Address
Student Address
Street Address Line 2
City
State / Province
Zip
Home Phone Number
Format: (000) 000-0000.
Has student ever attended a Minnesota Public School?
yes
no
Legal Father of Student Name (Last, First, Middle)
Legal Father of Student
Lives With
Education Rights
Release To
Deceased
Legal Father of Student Address
Legal Father of Student City
Legal Father of Student State
Legal Father of Student Zip Code
Legal Father of Student-Employer
Legal Father of Student Work Phone
Legal Father of Student Mobile Phone
Legal Father of Student Email Address
Legal Mother of Student Name (Last, First, Middle)
Legal Mother of Student
Lives With
Education Rights
Release To
Deceased
Legal Mother of Student City
Legal Mother of Student Address
Legal Mother of Student - State
Legal Mother of Student - Zip Code
Legal Mother of Student- Employer
Legal Mother of Student - Home/Cell Phone
Format: (000) 000-0000.
Legal Mother of Student -Work Phone
Format: (000) 000-0000.
Legal Mother of Student - Home/Cell Phone
Format: (000) 000-0000.
Legal Mother of Student - Email Address
example@example.com
Student Lives With:
Both Parents
Mother
Father
Step- Father
Foster Parent
Guardian
Other (include name below)
If Other Than Parents
Contact Allowed
Education Rights
Release to
Parent in Military
Yes
No
If you selected other, please include Name (Last, First, Middle)
If you selected other, please include Address
Address
Street Address Line 2
City
State / Province
Zip
Employer
Work Phone
Would you like the school to send correspondence to non-custodial parent?
yes
no
Emergency Contact #1 (other than parent/guardian)
Name
Relationship
Release To:
Yes
No
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Emergency Contact #2 Name (other than parent/guardian)
Relationship
Phone Number
Format: (000) 000-0000.
Release To:
Yes
No
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Transportation
My Child will
Walk
TownBus
Country Bus
I will transport
Other
Student Support Services- Check those services that this student receives
Developmental Delay/ ECSE
Speech/ Hearing
Occupational Therapy/Physical Therapy
Emotional/ Behavioral Disorder (EBD)
Learning Disabled
504
EMH/ TMH
Title 1
None of the Above
Storm Home
Transportation
Storm Home Name
First Name
Last Name
Address
Phone
Format: (000) 000-0000.
Foster Care.
Parents have rights. Home district
Parental Rights Terminated. Need court papers. .
Ward of state. Need court papers.
Have you moved to this school district within the last 36 months for temporary or seasonal agricultural or fishing work?
Yes
No
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