New Student Enrollment Student Information Sheet
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4Student Number: _____________________
NEW STUDENT ENROLLMENT – BREMEN HIGH SCHOOL
STUDENT INFORMATION SHEET
Student Name: _____________________________________________________________________________
Last Name
First Name
Middle Name
Address: __________________________________________________________________________________
House Number
Street Name
P.O. Box/Apt. #
__________________________________________________________________________________________
City
Zip Code
Phone Number
Cell Phone #
Birthday: ________________________
Height: ______________
Sex: _____ (Male) _____ (Female)
Month/Day/Year
NAME OF PARENT(S)/GUARDIAN(S) WITH WHOM YOU RESIDE:
(If not residing with natural birth parent or adoptive parent, who currently holds legal custody of this student, please
provide custody papers.)
Title (Check One)
Relationship (Check One)
____ Mr. and Mrs.
____ Mother and Father
____ Mr.
____ Mother and Stepfather
____ Mrs.
____ Father and Stepmother
____ Ms.
____ Mother only
____ Dr. and Mrs.
____ Father only
____ Rev. and Mrs.
____ Legal Guardian
____ Other (
)
____ Other (
)
Father’s Name: ______________________________
Mother’s Name: _____________________________
Address: ___________________________________
Address: ___________________________________
Phone #: ___________________________________
Phone #: ___________________________________
Email Address: _______________________________ Email Address: _______________________________
Work Place: _________________________________ Work Place: _________________________________
Work Phone #: ______________________________
Work Phone #: ______________________________
Work Address: _______________________________ Work Address: _______________________________
EMERGENCY INFORMATION
Emergency Contact: in case parent cannot be reached – Neighbor, relative or another person at work
Name: ____________________________________________ Phone #: ________________________________
Address: ______________________________________________ City: ________________________________
Doctor’s Name: __________________________________________ Phone #: ___________________________
Address: ______________________________________________ City: ________________________________
Hospital Preference: _________________________________________________________________________
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