Parents: If you could please fill this out by printing it OR simply write the information on a sheet of paper and send it by your student!
Student NAME: ______________________________________________ Period: _______________________
Parental/ Guardian Information:
Name: ____________________________________________________________________________________
Address: __________________________________________________________________________________
City: _____________________________________ State: _________________ Zip: ______________________
Daytime Phone #: (______)-______-________. Evening Phone #: (______)-______-________.
Cell Phone #: (______)-______-________.
*Please check one if you would like to be added to the regular mailing list for students.
Email Address #1: ______________________________________________________________________ ?
Email Address #2:______________________________________________________________________??
Secondary Guardian Information:
Name: ____________________________________________________________________________________
Address: __________________________________________________________________________________
City: _____________________________________ State: _________________ Zip: ______________________
Phone #: (______)-______-________. Cell Phone #: (______)-______-________.
*Please check if you would like to be added to the regular mailing list for students.
Email Address #1: ______________________________________________________________________ ?
***Emergency Contact: ______________________________________________________________________
Relationship to student: _________________________________ Phone: (______) - ______ - ________
Student Allergies: ___________________________________________________________________________
Preferred method of contact? ? Email ?USPS ?Phone
*After school tutoring will be available for students on Tuesday or Thursday from 2:20P.M. - 3:00P.M. by appointment/scheduling only- must be made at least one week in advance.
Do you allow the student to stay after school this semester (ending December 2010) for extra keyboarding time/tutoring? ? yes ?no --- If the student stays after school, what will be his/her mode of transportation at the end of tutoring time? ________________________________________________________
Parental Signature: ________________________________________ Date: _____________________________
Student Signature: ________________________________________ Date: _____________________________