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Student Information Form (demographic sheet)
8/25/2009

 

Meade County Schools
Student Information Sheet

 

 

Demographic Information

 

 

Student's Legal Name:_____________________________________________________________           GRADE_______

                                                       First                                Middle                                 Last

Custody of Student:   Parents   Mother & Stepfather  Father & Stepmother   Joint Custody (if applicable) 

                                                                     Foster Parent  Legal Guardian (by court)

Student's Transportation:  Bus # _________   Transported:  Over 1 mile   Under 1 mile 

                                                        Not Transported by Bus             Once daily  Twice daily

 

Primary Household   (This is the address where the above student resides.)

 

 

Home Address

                                  NUMBER                         STREET                                                                                         

 

                                   CITY                                                                                                STATE                                        ZIP

 

Mailing Address

   (if different)                     P.O. BOX      (OR OTHER MAILING ADDRESS)

 

                                            CITY                                                                                                STATE                                ZIP

 

Home Phone_______________________________

 

 

Parent or Guardian 1      (This is the primary parent/guardian for the student listed above.)


Name

                                            FIRST                                      MAIDEN/MIDDLE                                        LAST                               

 

Employer                                                                Work Phone                                                   Cell Phone__________________                                                         

 

 Parent   Legal Guardian (by court)   Stepparent   Foster Parent

 

Parent or Guardian 2       (This is either the second parent/guardian or a step-parent living in the household.)


Name

                                            FIRST                                       MAIDEN/MIDDLE                                       LAST                                

 

Employer                                                                Work Phone                                                   Cell Phone__________________                                                        

 

 Parent   Legal Guardian (by court)   Stepparent   Foster Parent

 

Secondary Household   (This section should be completed if both parents do not live in the Primary Household.)

 

 

Home Address

                                            NUMBER                         STREET                                                                                                 

 

 

                                            CITY                                                                                                STATE                                 ZIP

 

Mailing Address

   (if different)                     P.O. BOX      (OR OTHER MAILING ADDRESS)

 

                                            CITY                                                                                                STATE                                  ZIP

 

Home Phone ______________________________

 

Parent or Guardian 3  (This will generally be a parent who does NOT live in the Primary Household with the students.)


Name

                                            FIRST                                          MAIDEN/MIDDLE                                         LAST                               

 

Employer                                                                Work Phone                                                   Cell Phone__________________                                                         

 

 Parent   Legal Guardian (by court)   Stepparent   Foster Parent 

 

Parent or Guardian 4     (This will generally be the individual living with a parent in a Secondary Household.)


Name

                                            FIRST                                         MAIDEN/MIDDLE                                           LAST                                

  

Employer                                                                Work Phone                                                   Cell Phone__________________                                                         

 

 Parent  Legal Guardian (by court)    Stepparent    Foster Parent  

    


Students in Same Household Attending School  (Ages 3 and Above)

*Please list any additional students on a separate sheet of paper.

  

1st Student's LEGAL Name:  ____________________________________________________________________

                                                                                             FIRST                                          MIDDLE                                   LAST                    

  

Grade________________                       School_______________________________________________________

  

  

2nd  Student's LEGAL Name:  __________________________________________________________________

                                                                                             FIRST                                          MIDDLE                                   LAST                    

  

Grade________________                      School______________________________________________________

  

  

3rd Student's LEGAL Name:  ___________________________________________________________________

                                                                                             FIRST                                          MIDDLE                                   LAST                    

  

Grade________________                        School______________________________________________________

  

 

Emergency Contacts   *If a guardian cannot be contacted, we will release your child to the following individuals in the event of a true emergency.*

Name

Relationship

Home Phone

Work Phone

Cell Phone

o

  

  

  

  

o

  

  

  

  

  

•·         I verify that the information supplied is correct and current.

•·         I will inform the school of any changes in this information.

•·         I authorize any school personnel to take reasonable emergency measures on behalf of my child and agree to hold them harmless for any treatment rendered.

 

Parent/Guardian Signature _________________________________            Date: ___________________

  

  

  

  

  

  

  

  


                                                                                                                                                Revised 7/2009