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Student Information Sheet
Please complete this information and contact form at your earliest convenience. Thank you for making time for this. I will keep all of this information confidential.
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* Indicates required question
Student's Name (First and Last):
*
Your answer
Student's Nickname (if any):
Your answer
Student lives with:
*
Your answer
Language(s) Spoken at Home:
*
Your answer
Student's Mother's Name:
Your answer
Student's Father's Name:
Your answer
Additional Guardian Name(s) (if applicable):
Your answer
Preferred Phone Number:
*
Your answer
Additional Phone Number(s):
Your answer
Preferred Email Address:
*
Your answer
Additional Email Address(es):
Your answer
Health Concerns:
*
Yes
No
If you answered "yes" for Health Concerns, please describe those here:
Your answer
Additional Concerns (if any):
*
Yes
No
If you answered "yes" for Additional Concern, please explain those here:
Your answer
Usual Dismissal Procedure:
*
Car
Walker
EDP/After School
Bus
My child has access to the internet at home for school work:
*
Yes
No
My child has access to books at home:
*
Yes
No
Is there anything else you would like me to know about your child?
Your answer
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