Student Name *

Date of Birth *

Student Grade *

Primary Parent Contact Name *

Primary Parent Contact Email *

Primary Parent Contact Emergency Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

School Student Attends *

Who besides the primary parent is authorized to pick up this student?

Allergies

Medical Conditions

Learning Challenges that impact classroom behavior and/or performance

Medications

Note: We will not be able to administer medication during electives

Anything else that we need to know about this student?