ALLENEASTLOCALSCHOOLGRADESK–12STUDENT.docVIP

ALLEN EAST LOCAL SCHOOL GRADES K – 12 STUDENT INFO/ MEDICAL 2011 – 2012 STUDENT: _____________________________________________ DOB: _______________ S.S. #: ____________________________ (Last) (First) (Middle Initial) GRADE: _______________ BUS # ___________________ HOMEROOM TEACHER: ADDRESS: _____________________________ PO BOX#: _______________ CITY: _________________ ZIP: ___________________ EMAIL: _________________________________________ EMAIL: ____________________________________________ SEX: (CIRCLE ONE) M F NATIVE LANGUAGE: ____________________ HISPANIC/LATION HERITAGE: (CIRCLE ONE) YES NO ETHNICITY CODE: (CIRCLE ONE) A – ASIAN B – BLACK OR AFRICAN AMERICAN, NON-HISPANIC I – AMERICAN INDIAN OR ALASKAN NATIVE M – MULTIRACIAL P – NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER W – WHITE, NON- HISPANIC IS THERE A COURT CUSTODY FOR THIS CHILD? (CIRCLE ONE) YES* NO * IF YES, A CURRENT COPY OF THE CUSTODY ORDER MUST BE ON FILE IN THE STUDENT’S GRADE LEVEL OFFICE WHO IS THE RESIDENTIAL CUSTODIAN OF THIS CHILD? _________________________________________________ WHO DOES CHILD LIVE WITH? (CIRCLE ONE) BOTH PARENTS MOTHER ONLY FATHER ONLY GUARDIAN MOTHER/STEP- FATHER FATHER/STEP-MOTHER MOTHER’S INFORMATION FATHER’S INFORMATION Name: ___________________________________ Name: _________________________________________ Maiden Name: ____________________________ Address: _________________________________ Address: _______________________________________ City: ________________ Zip Code: __________ City: _____________________ Zip Code: ________ Home Phone#: ___________________________ Home Phone#: _____________