Fillable Middle School Student Household Information (Page 2 of 2) in pdf

Middle School Student Household Information Page 2

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Secondary Household/Members (Only for Parent NOT living in Primary Household)

Continued

□

Parent/Guardian 2:

_______________________________________________________________

Male

Female ______________________________

First/Given Middle Last

Relation to student

Employer:___________________________________________ Work phone:_________________________

E‐mail address: _____________________________________ Cell phone:__________________________

□ Legal Guardian □ Phone Messenger □ Portal Access □Mailing

Local Emergency Contacts:

The school needs a list of people that may be contacted in an emergency and must be able to pick up student.

Emergency Contact :________________________________________________________ Relation to student:_______________________

Home phone:______________________________Cell phone:__________________________ Work phone:_________________________

Emergency Contact :________________________________________________________ Relation to student:_______________________

Home phone:______________________________Cell phone:__________________________ Work phone:__________________________

Miscellaneous Contacts

Physician Name: _____________________________________________________________________

Phone:_________________________

Dentist Name:_______________________________________________________________________

Phone:_________________________

Daycare:_____________________________________________________________________________

Phone:_________________________

Does this student have special needs? □ No □ Yes If yes, check the box □ IEP □504 Plan □ Other

Court Protection Order? □ No □ Yes, against

Medical conditions:

Medication taken at home? □ No □ Yes, what and when

Medication taken at school? □ No □ Yes, what and when

Has this student been expelled from school? □ Yes □ No

Does this student have any prior or pending criminal charges? □ Yes □ No

If you answered yes to one or both of the preceding questions, please provide details (place, reason, dates, etc).

In case of emergency and if we are unable to locate you or your emergency contact, do you give the school district

or emergency personnel permission to treat your child ‐ including transporting your child by ambulance, if needed?

□ Yes □ No

I certify that I am the legal guardian of the child listed above and that all information above is true and accurate to the best

of my knowledge. I verify that I reside within the school district boundaries or have an approved non‐resident status

for my child.

Signature

Date

Middle School Student Household Information Page 2

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