Student Data Sheet
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1GATES INTERMEDIATE SCHOOL
STUDENT DATA SHEET
Dear Parent/Guardian:
The information you will provide below is very important to us. It will be used to contact you in the case of an emergency and to
support ongoing communication between school and home. To ensure this information is received and processed, please mail it, drop
it off, or return it to school with your child within the first week of school. We need a new information sheet filled in for each student
every year. Please indicate with a check mark ( ) any information that may have changed since last year.
Grade____________
Student Name_______________________________________________________________________________________________
first
middle
last
(full name as it appears on birth certificate)
Parent(s)/Guardian(s)_________________________________________________________________________________________
full name(s)
Street Address ______________________________________________________________________________________________
street
P.O. box
City/State/Zip ________________________________________________________________________________________________
city
state
zip
___________________________________________________________________________________________________________
home phone
gender
birth date
YOG
___________________________________________________________________________________________________________
primary email
secondary email
secondary phone
___________________________________________________________________________________________________________
city of birth
country of origin
native language
Mother
Father
Name
___________________________________
___________________________________
Employer
___________________________________
___________________________________
Employer phone number ___________________________________
___________________________________
Cell phone number
___________________________________
___________________________________
Emergency Contact___________________________________________________________________________________________
name
relationship
phone number
Family Physician _____________________________________________________________________________________________
name
phone number
Scituate High School uses Connect-ED, an automated communication system, to contact parents regarding issues of
attendance, information sharing, surveys, and also in emergency situations. Please provide the phone numbers and email
addresses at which you would prefer to receive and/or retrieve messages. These should be phone numbers and email
accounts from which parents/guardians regularly receive/retrieve communications.
Connect-ED Phone #1
______________________________ Connect-ED Email #1
______________________________
Connect-ED Phone #2
______________________________ Connect-ED Email #2
______________________________
________________________________________
________________________________________
Parent/Guardian Signature
Parent/Guardian Signature
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