Email Date Entering Grade Pre-School Kindergarten First Second Third Fourth Fifth Sixth Seventh Eight First Name Middle Name Last Name Gender Male Female Name Child Goes By Social Security Number Date of Birth Place of Birth White/Non-Hispanic White/Non-Hispanic Black/Non-Hispanic Black/Non-Hispanic American Indian American Indian Asian Asian Hispanic Hispanic School Last Attended: Student Lives With: Parents Parents Mother Mother Father Father Guardian Guardian Other Other Fathers Name Fathers Address Phone Number New Field Work Number Mother's Name Mother's Address Phone Number Mother's Address Work Number Guardian/Other Employer Work Number Primary Contact Email Address Siblings Emergency Contact Name Relation to Child Phone Emergency Contact Name Relation to Child Phone Physician Phone Preferred Hospital Other Information (disabilities, medications, etc.)