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Eva Gordon Elementary Teacher __________________ Student Information School Year _______________
Name _____________________________________________________Bus # ____________________ (LAST) (FIRST) Address ___________________________________________________Phone #___________________ (STREET) (Physical Address) (Home) ___________________________________________________ (CITY) (STATE) (ZIP CODE) Birthday __________________________________________________ SS # _____________________ (MONTH) (DAY) (YEAR) Race: Black Caucasian Asian Other________ Sex: Male Female
Guardian Information
Mother’s Name ______________________________________________ Work Phone #_______________ (LAST) (FIRST) Father’s Name ______________________________________________ Work Phone #_______________ (LAST) (FIRST) Legal Guardian’s Name _______________________________________ Work Phone #_______________ (LAST) (FIRST)
Emergency Information (Please list DIFFERENT phone numbers for each emergency contact.)
1) Name ___________________________________ Phone # ____________ Relationship_____________ (LAST) (FIRST) 2) Name ___________________________________ Phone # ____________ Relationship_____________ (LAST) (FIRST) 3) Name ___________________________________ Phone # ____________ Relationship_____________ (LAST) (FIRST) 4) Name ___________________________________ Phone # ____________ Relationship_____________ (LAST) (FIRST) Health Information
Allergies ______________________________________________________________________________ Other _________________________________________________________________________________
IF YOU WANT YOUR CHILD TO RIDE A DIFFERENT BUS, WE MUST HAVE A WRITTEN NOTE SIGNED BY THE PARENT OR LEGAL GUARDIAN.
______________________________________________ ___________________ SIGNATURE OF PARENT OR LEGAL GUARDIAN DATE
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