Blue Data Collection Form Student
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2RETURN THIS FORM TO ROOM 029
BLUE DATA COLLECTION FORM
S1
OSIS #
Student’s LAST Name
Student’s FIRST Name
Home Phone# (
) ______________________ Student’s Cell#(
)____________________
**Student’s Cell Company_______________________
Sex _M / F__
Date of Birth ________
/________ /________
2
*Parent #1 LAST Name (Student Resides with)
Parent #1 FIRST Name
Parent #1 Preferred Language: Written_______________ Oral________________
Cell#(
)_________________ **Cell Company___________________________ Relationship__________________
Parent #1 e-mail
Parent #1 Address ______________________________________________________________________________________________ Apt#____________ Boro__________________ ZIP_______________
*Parent #1 Home Tel# (
) _________________________________
* Work Tel# (
) __________________________________
*Please note that Parent # 1 telephone numbers are the only numbers which will be called by our automated phone system.
** In the event of a serious emergency Mass Emergency Messages will be sent via text messaging. The name of your Cell Phone Carrier is necessary if you would like to receive emergency messages via text
messaging. Charges may be incurred based on you cell carrier’s service agreement. If you do not want to be notified using text messaging, you may leave Cell Phone Carrier blank.
Parent #2 LAST Name
Parent #2 First Name
Parent #2 Preferred Language: Written_________________ Oral__________________
Cell#_(
)_____________________ **Cell Company_______________ Relationship______________________
Parent #2 e-mail
Parent #2 Address ______________________________________________________________________________________________ Apt#____________ Boro__________________ ZIP_______________
Parent #2 Home Tel# (
) _________________________________
Parent #2 Work Tel# (
) __________________________________
Please list below the names of three (3) persons who may be called in case of emergency or if your child is sick in school.
I will inform the principal or his/her
CHILD WILL BE RELEASED ONLY TO PERSONS NAMED BELOW
designee if any of the information on this
Name _____________________________________ Tel# (
) _____________________________
Relationship ____________________
form changes.
Name _____________________________________ Tel# (
) _____________________________
Relationship ____________________
Name _____________________________________ Tel# (
) _____________________________
Relationship ____________________
If there is a person who MAY NOT HAVE ACCESS to your child, please indicate:
_________________________________________
Signature of Parent / Guardian
Name _____________________________________ Relationship ______________________
Order of Protection Exists? Yes____ No____
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