Student Information Sheet

Student Information Sheet
Student Information
Name of Student*

First NameLast Name
Student's Date of Birth*

MonthDayYear
Date
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School (if applicable)
Grade Level*
Language Spoken at Home*
Special Needs or Accommodations
Any extracurricular activities or interests
Additional Comments or Notes
Parent/Guardian Information:
Parent/Guardian Name*

First NameLast Name
Relationship to Student

MotherFatherStep-ParentGuardianOther
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Parent/Guardian Name*

First NameLast Name
Relationship to Student

MotherFatherStep-ParentGuardianOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Occupation
Educational Level
Emergency Details 1
Emergency Contact Name*

First NameLast Name
Relationship to Student*

ParentGuardianRelativeOther
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Emergency Details 2
Emergency Contact Name*

First NameLast Name
Relationship to Student*

ParentGuardianRelativeOther
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Occupation
Educational Level
Additional Information:
Please list any relevant medical conditions, allergies, or medications
Consent and Authorization:
Please tick the boxes below*

I agree to grant my consent to manage emergencies if no contact is establishedI will keep my sick child home and notify the programI will supply any necessary medicationI consent to photography or videography of my child for marketing purposedI consent to pay any medical charges or expenses that could be incurred in case of emergency.
By signing below, I hereby authorize the Flourishing Minds Academy to use the information provided for educational and administrative purposes. I certify that the information provided is accurate and complete to the best of my knowledge.
Parent/Guardian Signature (if student is a minor)

Powered by Jotform SignClear
Date Signed

MonthDayYear
Date
Should be Empty:

Student Information Sheet

Student Information

Parent/Guardian Information:

Emergency Details 1

Emergency Details 2

Additional Information: