REGISTRATION STUDENT INFORMATION – Please Print STUDENT’S LEGAL LAST NAME
LEGAL FIRST NAME
MIDDLE NAME
DATE OF BIRTH
GENDER
GRADE
PREFERRED NAME HOME ADDRESS (Street Address & Apt. No.)
CITY
STATE
MAILING ADDRESS (If Different From Home)
CITY
STATE
LAST SCHOOL ATTENDED
RACE/ETHNICITY: (Choose all that apply) ☐African American ☐American Indian/Alaskan Native ☐Hispanic ☐Other
☐Asian
ZIP CODE
HOME PHONE #
ZIP CODE
STUDENT’S EMAIL
CITY
STATE
☐Caucasian
√ IF APPLICABLE ____ Unlisted ____ Cell
ZIP CODE
☐Hawaiian/Pacific Islander
LEGAL DOCUMENTS: (Restraining order, Custody Agreements and any other court documents) ☐ YES – Please provide documents ☐ NO
PARENT / GUARDIAN INFORMATION PARENT/GUARDIAN NAME
☐ YES ☐NO
LIVES WITH STUDENT? RELATIONSHIP TO STUDENT:
HOME ADDRESS (If different from above)
CITY
State
EMPLOYER
ZIP CODE
WORK PHONE
PARENT/GUARDIAN NAME
EMAIL ADDRESS
HOME PHONE
LIVES WITH STUDENT?
CELL
☐ YES ☐NO
RELATIONSHIP TO STUDENT:
HOME ADDRESS (If different from above)
CITY
State
EMPLOYER
ZIP CODE
WORK PHONE
EMAIL ADDRESS HOME PHONE
CELL
EMERGENCY CONTACT INFORMATION – Please list at least two persons not listed above. Any person listed may be contacted in an emergency; parent/guardian contact will be attempted first. Any person listed may pick student up from school.
NAME (Please print)
RELATION TO STUDENT
HOME #
CELL #
WORK #
LIVES W/ STUDENT? ☐YES ☐NO
NAME (Please print)
RELATION TO STUDENT
HOME #
CELL #
WORK #
LIVES W/ STUDENT? ☐YES ☐NO
NAME (Please print)
RELATION TO STUDENT
HOME #
CELL #
WORK #
LIVES W/ STUDENT? ☐YES ☐NO