Student Information

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Student Information

Child's Name *

Child's Birthdate *

YYYY

Address (where child resides) - NOTE: If parents are separated and have shared custody, please list both addresses. *

Mother's (or Guardian's) Name: *

Mother's (or Guardian's) Place of Work: *

Mother's (or Guardian's) Work Phone: *

Mother's (or Guardian's) Cell Phone: *

Mother's (or Guardian's) Home Phone (if different than cell): *

Mother's (preferred) Email Address: *

Father's (or Guardian's) Name: *

Father's (or Guardian's) Place of Work: *

Father's (or Guardian's) Work Phone: *

Father's (or Guardian's) Cell Phone: *

Father's (or Guardian's) Home Phone (if different than cell):

Father's (preferred) Email Address: *

Preferred Contact - Name and Number *

Emergency Contact (someone other than a parent/guardian)- Name, Relationship and Number *

Where will your child be learning remotely from (home, daycare, grandparents, etc.)? *

Medical Concerns (medicines, allergies, etc.) *

Will your child eat lunch provided by the school (bus drop off)? *

Will your child most likely be able to participate in zoom class meetings as scheduled during the day or have to watch the recorded zoom lessons at a later time during the day? *

will participate in regularly scheduled zoom classes during the day

will watch the recorded zoom lessons, review lessons and concepts with parent and complete work at a later time during the day

will do a combination of the above, depending on family's schedule

Does your child wear glasses? *

Yes

Please take a few moments to give me some information about your child (likes, dislikes, quirks, fears, strengths, weaknesses, etc.) as well as let me know of any concerns or questions you have in regards to your child's academic, social or emotional well being (or anything else that will help me meet the needs of your child in the the best way possible).

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