Change Of Student Information Form January 2014
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1Student Name _________________________
Please Print
BREVARD PUBLIC SCHOOLS
CHANGE OF STUDENT INFORMATION
Returning Students ONLY
Use ONE form per family and ONE form per school. List all students.
Effective Date: ________________________________
(Please print clearly)
STUDENT RESIDES WITH: _______________________________________________ Relationship: _____________________
Student’s name_____________________________________________ Grade __________School _____________ ID# __________
Student’s name_____________________________________________ Grade __________School _____________ ID# __________
Student’s name_____________________________________________ Grade __________School _____________ ID# __________
Student’s name_____________________________________________ Grade __________School _____________ ID# __________
Student resides with (Circle ONE) Mother/Father
Guardian
Stepmother/Father
Stepfather/Mother
Address change: (MUST furnish proof of your residence with two of the following: Current Homestead Exemption Card or
Purchase Contract (with expected closing date within 90 days of school) or Warranty Deed; Lease/rental agreement (with your
name as the renter); Current utilities statement (within the last 30-45 days); Driver’s License – F. S. 322.19 (2) requires that you
update your address information on your driver’s license within ten days of moving.)
OLD address: _______________________________________________________________________________________________
NEW address: ______________________________________________________________________________________________
Housing addition or Apartment Complex: _________________________________________________________________________
Change of home phone: Mother/Guardian: ___________________________ Father/Guardian: ____________________________
Change of cellular/pager: Mother/Guardian: ___________________________ Father/Guardian: ____________________________
Change of work phone: Mother/Guardian: ___________________________ Father/Guardian: _____________________________
E-mail (Mother): ______________________________________ E-mail (Father): _________________________________________
Change/Addition to emergency contact: (other than parent)
Person: __________________________ Gender: _______ Relationship: ______________________ Able to pick up child? Y N
Home Phone: _________________________ Cell: ________________________ Work Phone: _________________________
Person: __________________________ Gender: _______ Relationship: ______________________ Able to pick up child? Y N
Home Phone: _________________________ Cell: ________________________ Work Phone: _________________________
Person: __________________________ Gender: _______ Relationship: ______________________ Able to pick up child? Y N
Home Phone: _________________________ Cell: ________________________ Work Phone: _________________________
Change of marital status:
New name: __________________________________________________________________________________________
Change of custody: (choose ONE) (Must provide court documentation)
Father to Mother
Mother to Father
Guardian to Parent
Parent to Guardian
Change of name for STUDENT: (Must provide birth certificate or court documentation.)
From (name):________________________________________________________________________________________
To (name): __________________________________________________________________________________________
____________________________________________________
Parent/Guardian Name (Please print)
Parent/Guardian Signature:
___________________________________________ Date: ________________________________
Revised by Student Services January 2014
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