State

Student Information

Last Name

First Name

Date of Birth

Address	l

City

State

Zip

Home Phone	()-	___

School I.D. (4 numbers)

Official Class

If a 4 dighit school ID has been assigned
please enter it here. If not, please leave
this space blank.

If your child's official class has been 
assigned please enter it here. If not,
 please leave this space blank.

OSIS Number

Contact Information

Mother or
Guardian's Name

Mother or
Guardian's Work Phone

()-

Father's Name (or Grandmother/Aunt/Family Friend, etc)

Father's (or Grandmother/Aunt/Family Friend,etc) Home Phone

()-

Any other number where you can be reached?



Student email Address (optional)

Any comments that you would like to make?