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Pueblo School District 70
A School-within-a-School at Pueblo County High School
School of
and
ENGINEERING
BIOMEDICAL SCIENCE
Last School Attended District
Student Information
Home Address City State Zip

Mailing Address (if different) City State Zip

Phone
Last Name First Middle Current Grade
Male / Female
Social Security Number
Date of Birth
Parent / Guardian Information
Home Address City State Zip

Last Name First Relationship Home Phone
Work Phone
First Contact
Home Address City State Zip

Last Name First Relationship Home Phone
Work Phone
Second Contact
Parent / Guardian Signature
x
Date
Please return completed form to: School of Engineering and Biomedical Science
1050 Lane 35
Pueblo, CO 81006
Ofce Use Only:
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Ethnicity (choose one):
___ American Indian / Alaska Native (01)
___ Asian or Pacic Islander (02)
___ Black (not Hispanic) (03)
___ Hispanic (04)
___ White (not Hispanic) (05)
___ I do not wish to provide this information