Personal Student Data Sheet

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PERSONAL DATA SHEET – Lexington City Schools
(Revised May 2005)
TO BE COMPLETED BY OFFICE
________________________________
____________________
Tuition Paid if Out of District Student ______
School
Year
Student Number________________________
Entry Date ____________________________
Our educators need this information in order to give your child the best possible care
Entry Code____________________________
in case of an emergency of any other service he/she may require. IF ANY OF THIS
Teacher __________________ Grade ______
INFORMATION CHANGES, PLEASE NOTIFY THE OFFICE.
1. Child’s Full Name: (As it appears on Birth Certificate or Court Document)
____________________________________ ____________________________________ ________________________________
(Last Name)
(First Name)
(Middle Name)
2. Mailing Address:
__________________________________ ____________________ ______________________________ ____________________
(Street Address – REQUIRED)
(P.O. Box)
(Name of City)
(Zip Code)
3. Phone #: _____________________
4. Date of Birth: __________________
5. Race: _____________
6. Sex: M
F
7. Name of Last School Attended:
8. Name of Person Child Lives With: _____________________________________________________________
______________________________________________________________________________ ____________________________
(Address)
(Phone)
9. Relationship to Student: (Please circle one.)
Mother and Father
Mother and Stepfather
Father and Stepmother
Mother Only
Father Only
Guardian
10. Mother’s Name:__________________________________ Mother’s Address: _________________________________________
Mother’s Phone #:________________________________ Mother’s Work Place: ______________________________________
Address of Mother’s Work Place:_________________________________ Mother’s Work Phone #:________________________
11. Father’s Name:__________________________________ Father’s Address: __________________________________________
Father’s Phone #: ________________________________ Father’s Work Place: ______________________________________
Address of Father’s Work Place: _________________________________ Father’s Work Phone #:_______________________
12.FOR EMERGENCY USE ONLY: PLEASE LIST NAME OF PERSON THAT SHOULD BE CONTACTED IF WE ARE UNABLE TO
GET IN TOUCH WITH YOU. PLEASE LIST 2 OR 3 NAMES. DO NOT USE NUMBERS ABOVE SINCE PARENT/GUARDIAN
WILL ALWAYS BE CALLED FIRST. THIS INFORMATION IS USED IF WE CANNOT REACH PARENT/GUARDIAN AT ANY OF
THE ABOVE NUMBERS.
Name: _________________________________ Relation:___________________ Phone: ____________________
Name: _________________________________ Relation:___________________ Phone: ____________________
Name: _________________________________ Relation:___________________ Phone: ____________________
Doctor’s Name: __________________________ Phone: ____________________
13. LIST ANY MEDICAL PROBLEM THAT YOUR CHILD HAS THAT OUR STAFF SHOULD KNOW ABOUT:
14. FOR NON-EMERGENCIES: IF YOU DO NOT HAVE A TELEPHONE, PLEASE LIST THE NAME AND TELEPHONE NUMBER OF
YOUR TWO NEAREST NEIGHBORS WHOM WE MAY CONTACT WHO WILL AGREE TO LET YOU KNOW IF WE NEED TO
GET IN TOUCH WITH YOU DURING THE SCHOOL DAY.
Name: _________________________________ Relation:___________________ Phone: ____________________
Name: _________________________________ Relation:___________________ Phone: ____________________
15. Circle student’s transportation home from school and supply indicated information:
Bus (List bus number)__________AM ________ PM
Van (list which van) _________ AM __________ PM
Car (List the adult your child will ride with)_____________________AM ________________________________ PM
Walk (List where your child will walk to )______________________ AM ________________________________ PM
Other Transportation Information: ___________________________ AM ________________________________ PM

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