_______________________________________ _______________

First Name

Last Name

Nickname

__________________ ____________________________________
Birthdate

Any Allergies?

________________________________________ ______________
Home Address

City

State

Zip Code

Home Phone #

___________________ _________________ _________________

Mothers Name

Mothers Cell #

Mothers Work #

___________________ _________________ _________________

Fathers Name

Fathers Cell #

Fathers Work #

Preferred Email Address __________________________________________

(required for weekly newsletter & daily communication)

Student lives with:

Mother

In Case of an Emergency, call:

Father

Both Parents

Guardian:_______________

______________________ at: _______________

(other than parent)

Relationship to student:

___________________________________________
Transportation from school
first

KidsNet
walk with:

parent pick up

__________
Reamainder

KidsNet
walk with:

parent pick up

__________

day:

Bus: __________
daycare van:

__________

of the year:

Bus:

__________

daycare van:

__________