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Welcome to the 2021-2022 school year at BCA! The information on this form will serve as the primary contact reference for the school. Please contact the school if any of the information changes.
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Email
*
Your email
BIOGRAPHICAL INFORMATION - STUDENT
Student Last Name *
*
Your answer
Student First Name
*
Your answer
Student Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Female
Male
Student Grade
*
9th
10th
11th
12th
Does the student have any allergies / medical issues that we should be aware of ?
Your answer
PARENT/GUARDIAN INFORMATION
Parent/Guardian #1 (Last Name , First Name)
*
Your answer
Relation to student:
*
Mother
Father
Grandparent
Legal Guardian
Other:
Mailing Address including Zip Code
*
Your answer
Parent Email Address
Your answer
Parent Cell or Primary Phone Number
*
Your answer
Parent/Guardian Contact #2 (Last Name , First Name)
*
Your answer
Contact #2 Cell/Phone Number
*
Your answer
Is the student registered with the Montefiore Clinic on Campus?
*
Yes
No
By clicking the SUBMIT button, I understand that I am electronically signing this document and that all of the information entered is true, accurate and submitted by the legal guardian.
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