Last Name:            First Name:     Initial:

Nickname:           Age:          Birth Date:      Gender: M F

Father or Guardian                                     Mother or Guardian

Name:                           Name:

Address:                          Address:

City/State/Zip:             City/State/Zip:

Home Phone:           Home Phone:

Work Phone Ext.           Work Phone: Ext.

Cell Phone:            Cell Phone:

E-Mail Address:            E-Mail Address:

Hours of Employment:           Hours of Employment:

Employer:           Employer:

Position:            Positions:

Sibling Information
Name:           Gender: M F   Birth date:

Name:           Gender: M F   Birth date:

Name:           Gender: M F   Birth date:

Grandparent Information (optional)
Paternal Grandparents                                      Maternal Grandparents
Name:             Name:

Address:          Address:

City/State/Zip:       City/State/Zip:

Phone:       Phone:

Student lives with:        Both Parents         Mother                  Father          Other
Check if:                      Parents Together       Parents Separated     Parent Divorced
                                      Mother Deceased      Father Deceased

Other Information

Primary Language at Home:         
Secondary Language:

Briefly describe your child’s personality, including strengths:

Are there any areas of concern we should be aware of?  Please describe

Are there any special family circumstances that we should be aware of ?

Is there any health or medical problem that we should be made aware of?

Does your child have allergies?