Step 1 of 2 50% Child InformationFirst Child's Name(Required) First M.I. Last Entering Grade Male Female Prefer not to specify Birth Date Month Day Year Birth City/State City State Social Security # Existing medical conditions, medications and/or special attention your child may require: Allergies: May we take and maintain a photo of your child for security purposes? Yes No Do you have a second child to register? Yes No Child Information- Second ChildSecond Child's Name First Last Entering Grade Male Female Prefer not to specify Birth Date Month Day Year Birth City/State City State Social Security # Existing medical conditions, medications and/or special attention your child may require: Allergies: May we take and maintain a photo of your child for security purposes? Yes No Do you have a third child to register? Yes No Child Information- Third ChildThird Child's Name First Last Entering Grade Male Female Prefer not to specify Birth Date Month Day Year Birth City/State City State Social Security # Existing medical conditions, medications and/or special attention your child may require: Allergies: May we take and maintain a photo of your child for security purposes? Yes No Primary Guardian InformationName(s) of person(s) with whom the child is living1st Primary Guardian Name First M.I. Last Relationship to Child Email Work PhoneCell PhoneOccupation Employer Work Address Work Hours Is there a 2nd primary guardian?(person with whom the child is living) Yes No 2nd Primary Guardian2nd Primary Guardian Name First M.I. Last Relationship to Child Email Work PhoneCell PhoneOccupation Employer Work Address Work Hours Which guardian should be called first? HomeAddress Street Address Apt # City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code mailing address same as above Mailing Address Street Address Apt # City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhonePrefered language for written communication: Second Guardian InformationNon-primary custodial parentNon-primary Guardian First M.I. Last Relationship to child Email Work PhoneCell PhoneHome PhoneAdditional Comments & Information Emergency Contacts and Authorized Pickups1st Contact/Pickup First Last Relationship to child Home PhoneCell PhoneSpecify which children may be picked up by this person Able to pick up all children in the family Other 2nd Contact/Pickup First Last Relationship to child Home PhoneCell PhoneSpecify which children may be picked up by this person Able to pick up all children in the family Other 3rd Contact/Pickup First Last Relationship to child Home PhoneCell PhoneSpecify which children may be picked up by this person Able to pick up all children in the family Other Additional Comments and InformationIs there any other information that would be helpful to our management and teaching staff?
