Student Information Form

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Student Information Form
4/16
Today’s date
Student’s name as shown on birth certificate or I-94:
First name
Middle
Last Name
Name student prefers to be called
School the student most recently attended
Student’s date of birth
_______________________ Grade in school for 2016-17
Student’s home address with zip code
How did you learn about Utah International Charter School?
Parent/Guardian first and last name
Parent/Guardian phone numbers: Home
Cell
Work
Relationship to student (mother, father, other)
Parent/Guardian email address if available
Parent/Guardian first and last name
Parent/Guardian phone numbers: Home
Cell
Work
Relationship to student (mother, father, other)
Parent/Guardian address if different from student
Parent/Guardian email address if available
In case of emergency, if we cannot reach you, please list two adult family members or friends we can contact,
and that you authorize to check your student out of school if necessary.
Name
Phone number
Name
Phone number
Student’s regular doctor or health care provider
Name
Phone number

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