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Name (last, first, MI)            ,    

Highest Grade Level Completed

Home
Street, Apt/Suite                   
City, State, Zip                    ,    

Mailing Address (if different from above)
Street, Apt/Suite                   
City, State, Zip                    ,    

Home Phone                         

Date of Birth                        

 

Father (last, first)                 

Father's Work  Phone                 Father's Cell Phone 

Father's Employer                 

Father's Home Phone            

 

Gender                                  

Guardianship                       

Email                                     

 

Mother (last, first)                

Mother's Work  Phone               Mother's Cell Phone 

Mother's Employer               

Mother's Home Phone        

Student's Social Security #  (minimum last 4 digits required)

 


 

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Emergency Contact/Medical Information

Contact #1
Contact Name (last, first)           Relationship
Phone                                         Phone Type



Contact #2
Contact Name (last, first)           Relationship
Phone                                         Phone Type



Contact #3
Contact Name (last, first)           Relationship
Phone                                         Phone Type



Doctor                                       Phone

Special Medical Considerations

Allergies

Medical Alert Text

Alert Expiries (date)