STUDENT INFORMATION FORM First Name Last Name Child's Address City, State, Zip Code If different from Child's Address 1st Parent's Address 2nd Parent's Address Siblings: Name/Age/Gender: Parents' marital/relationship status: Describe living arrangements, if step-family, co-parenting with former spouse, etc.: 1st Parent's Employer Work Phone 2nd Parent's Employer Work Phone Name of Child's Physician Address City, State, Zip Code Phone Number Name of Child's Dentist Address City, State, Zip Code Phone Number Name of persons authorized to pick up child other than parents: Name First Name Last Name Address City, State, Zip Code Phone Number Name First Name Last Name Address City, State, Zip Code Phone Number Name of persons to be notified in case of emergency if parents cannot be reached: Name First Name Last Name Address City, State, Zip Code Phone Number Name First Name Last Name Address City, State, Zip Code Phone Number Please list additional guardian information: Thank you!
