Date Form Completed: ____________________________________________

Student’s First Name: ____________________________________________

Student’s Middle Initial: ____

Student’s Last Name: ____________________________________________

Student’s Birth Date:_____________________ Gender: _________________

Student’s Grade (Fall, beginning of school year): _______________

Parent(s)/Guardian(s) name(s): _____________________________________

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Parents’ e-mail address ___________________________________________

Home Address:___________________________________________________

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Home Phone: (        )_____________ Cell Phone: (        ) ________________

Student’s e-mail address ___________________________________________

Allergies or special needs: _________________________________________

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Sibling’s Name(s): ______________ _______________ __________________

Sibling’s Date of Birth:_____________ ______________ _________________

Sibling’s Grade(s): ______ ______ ______