Sample High School Student Information Sheet
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1S t u d e n t I n f o r m a t i o n S h e e t
V a l e n t i n e H i g h S c h o o l
_ _ _ _ _ _ _
D a t e
Name
Age
(Last)
(First)
(Middle)
Birthdate
Place:_____________________ Grade Level:_____________
Month
Day
Year
Social Security Number__________________________ Ethnicity____________Gender (M or F) _______
Home Phone
Father's workplace____________________________Work Phone or cell
Mother's workplace____________________________Work Phone or cell
First Language Learned:___________________ __ Home Language: ________________
Custodial Parent(s) _____________________________________________________________
Custodial Parent's Address
: ___________________________________
(If different from Parent's)
Student's School Address
Student resides with: Custodial parent(s), Non-Custodial Parent(s), other ___________
(please circle one of the above)
Previous School District attended: ___________________ Number of years: ________
County _____________________City_______________State
__________________
Is your child eligible for Special Education Services? ___________________________
Please list names of all brothers and sisters:
Brothers
Age
Sisters
Age
Vehicle Make/Model and License Plate # of vehicle(s) student will drive to school:
_____________________________________________________________________
Non Custodial Parent Information
Non-Custodial parent’s name______________________________________________
Non-Custodial parent’s address ____________________________________________
Non-Custodial parent’s work or cell phone _________________________________________
Any problem with non-custodial parent having contact with your student or (his/her) grades?_________________
Student’s Health History
_____________ Doctor’s Phone______________________
Family Doctor's Name
Health conditions or allergies we need to be aware of
are:__________________________________________________________________
I hereby give permission for Valentine High School to give Tylenol to ____________________ as
needed while attending school there. I understand that if there is a change in their medical status
such as an allergy to certain over the counter drugs, it is my responsibility to notify the school of
any changes. ________________________________________ (Signature of Parent or Guardian)
Emergency Contact Information:
Name:__________________________________, Phone: _______________________
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