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| 2019 - 2020 | 4th Grade - Milstein 208 | Student Information Survey
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* Indicates required question
Child's Name (first & last) please use name child will go by in class
*
Your answer
Mother/Guardian's Name (first & last)
*
Your answer
Mother/Guardian's Preferred Phone Number
*
Your answer
Mother/Guardian's Email Address
*
Your answer
Father/Guardian's Name (first & last)
*
Your answer
Father/Guardian's Preferred Phone Number
*
Your answer
Father/Guardian's Email Address
*
Your answer
Additional Guardians & Contact Information
Your answer
Primary Street Address
*
Your answer
Primary Zip Code
*
Your answer
Child's Birthday
*
MM
/
DD
/
YYYY
Student Allergies or Medical Information
Your answer
Please list any medication your child will have at school.
Your answer
If your child has medication at school, where will it be located?
Classroom
Nurse's Office
Backpack
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Other Important Information
Your answer
Regular Dismissal Schedule
*
Pick-Up/Walker
Bus
21st Century/After School Class
Other (please provide details in "Important Information")
Monday
Tuesday
Wednesday
Thursday
Friday
Pick-Up/Walker
Bus
21st Century/After School Class
Other (please provide details in "Important Information")
Monday
Tuesday
Wednesday
Thursday
Friday
I am okay with my name & contact information being shared with the other parents of Room 208
*
yes
no
I consent to my child being photographed for sharing within the class group (on class website/in emails)
*
Yes
No
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