Student Information - Living Atrs Sciene Center


362 N Martin Luther King Blvd.
Lexington, KY 40508.
We want our students to have a happy and enriching experience at the LASC. Please provide us with any
information that could assist in attaining this goal. This information is confidential and will only be shared
with staff members involved directly with the student. Please submit this form prior to the first day of class.
Student’s name _____________________ Birth Date _________ Last Grade Completed ______________
Parents / Guardians
Name ______________________________ Relationship _________________
(if student is under 18)
Name ______________________________ Relationship _________________
Please provide us with your current phone number(s) and indicate the owner of each number:
First # to call __________________________ Home/Cell/Work Whose phone is this? _______________
Second # to call _______________________ Home/Cell/Work Whose phone is this? _______________
Third # to call _________________________ Home/Cell/Work Whose phone is this? _______________
Place(s) of Employment __________________________ E-Mail(s) ________________________________
Who will normally provide transportation? ___________________________________________________
(Include first and last names of all transportation, including parents/guardians listed above. We require a
signed note for anyone else to pick up a student under 18.)
Emergency Contact Name (someone NOT listed above) _________________________________________
Emergency Contact Phone # ___________________________ Relationship to student ______________
1. What are your expectations for you or your child’s class experiences at the LASC?
2. Please list student allergies as well as all pertinent medical, physical, emotional and social concerns.
3. Do you have any other concerns or suggestions for those working with you or your child?
I give permission for the Living Arts & Science Center or those designated by the LASC to collect
___ No
and use the likeness, photograph, voice, written word, artwork or direct quotes of the above named student. Such
documentation may be used on the LASC website, in promotional materials, the newspaper, or other such
materials. I release the Living Arts & Science Center from any liability or responsibility for this use.
By signing below, I certify that all information provided on this form is accurate and that I have read, understand, and agree to
adhere to LASC guidelines and policies found in Imagine That and on the LASC website.
Signature (Parent Signature if student is under 18)


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