Student Contact Information Form - Baltimore City Public Schools
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1
2School Name:
Student Contact Information Form
Please print and fully complete BOTH SIDES of this form.
Student name: ________________________________________________ Birth date: ___/___/_____ Gender:
F
M
Last
First
Middle
Month Day Year
Student home address: ____________________________________________________________________________________
City: _________________________________________________________ Zip: _____________________________________
Mailing address (if different from home address): ________________________________________________________________
City: _________________________________________________________ Zip: _____________________________________
Are you temporarily living with others due to a lack of permanent housing, living in a shelter, living in a hotel, or otherwise homeless?
Y
N
Parent/Guardian Information
Parent/guardian 1 name: _________________________________________ Relationship: _____________________________
Home phone: ____________________ Cell phone: ____________________ Preferred language: _______________________
Would you like to receive text messages* at the above cell phone number with important information from the district or school,
such as school closings or upcoming events?
Y
N
Work phone: ________________________________ Email: _____________________________________________________
Lives with student
Has custody of student
Has permission to pick up student
Gets mailings for student
Parent/guardian 2 name: ________________________________________ Relationship: _____________________________
Home phone: ____________________ Cell phone: ____________________ Preferred language: _______________________
Would you like to receive text messages* at the above cell phone number with important information from the district or school,
such as school closings or upcoming events?
Y
N
Work phone: _______________________________ Email: ______________________________________________________
Lives with student
Has custody of student
Has permission to pick up student
Gets mailings for student
Emergency Contact 1
Name: _______________________________________________________ Relationship: _______________________________
Home phone: ____________________ Cell phone: ____________________ Work phone: ____________________________
E-mail: ____________________________________________
Preferred language: ___________________________________
Emergency Contact 2
Name: _______________________________________________________ Relationship: _______________________________
Home phone: ____________________ Cell phone: ____________________ Work phone: ____________________________
E-mail: ____________________________________________
Preferred language: ___________________________________
A change in address requires documentation. Additional contacts can be added. Please check with your school.
________________________________________________________
_______________________________
Parent/guardian signature
Date
*Text message charges may apply, depending on your cell phone plan. Please check with your provider.
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