Student Information Form Page 2
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2Lakeland Christian Academy
Student Information Form ~ Page 2
Emergency Contact/Authorized Pick-up People
Contact (1) Name:____________________________________________________________________
Address:______________________________ City, State, Zip ________________________________
Phone # (___)___________Second Phone # (___)____________Relationship to Child:_____________
Emergency Contact: (____) Yes (____) No
Authorized to Pick Up: (____) Yes (____) No
Contact (2) Name:____________________________________________________________________
Address:______________________________ City, State, Zip ________________________________
Phone # (___)___________Second Phone # (___)____________Relationship to Child:_____________
Emergency Contact: (____) Yes (____) No
Authorized to Pick Up: (____) Yes (____) No
Contact (3) Name:____________________________________________________________________
Address:______________________________ City, State, Zip ________________________________
Phone # (___)___________Second Phone # (___)____________Relationship to Child:______________
Emergency Contact: (____) Yes (____) No
Authorized to Pick Up: (____) Yes (____) No
Contact (4) Name:____________________________________________________________________
Address:______________________________ City, State, Zip ________________________________
Phone # (___)___________Second Phone # (___)____________Relationship to Child:______________
Emergency Contact: (____) Yes (____) No
Authorized to Pick Up: (____) Yes (____) No
Contact (5) Name:____________________________________________________________________
Address:______________________________ City, State, Zip ________________________________
Phone # (___)___________Second Phone # (___)____________Relationship to Child:______________
Emergency Contact: (____) Yes (____) No
Authorized to Pick Up: (____) Yes (____) No
PARENT’S ACKNOWLEDGEMENT
The information provided on this form is true to the best of my knowledge. I am this child’s par-
ent or legal guardian.
___________________________________________
____________________
Signature of Parent/Legal Guardian
Date
397 S. Stemmons Freeway, Lewisville, TX 75067 (972) 219-3939
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