(Please type or use black ink only)                                   Social Security #                                                                 

 

DALLAS SCHOOL DISTRICT

Dallas, Pennsylvania

 

Student’s Name                                                                                                Sex                         Birth Date                                          

 

Address                                                                                                                                            Phone                                   

                    

Please check if change in address

               

                Father’s Name                                                                  Mother’s Name                                                                

 

                Father’s place of employment                                                                                      Phone                                  

 

                Mother’s place of employment                                                                                    Phone                                   

 

Child lives with:             Both Parents                 Father                   Mother  Phone                                  

 

                                                Other                                                                                                   

                                                                (first-last name)                                    Relationship to child

In case of serious accident or illness, please contact the following person:

 

Name                                                   Relationship                                          Phone                          

 

Name                                                   Relationship                                          Phone                          

 

                If necessary, do you have transportation?                        Yes                  No

 

Family doctor                                                                                                    Phone                          

 

Hospital Preference                                                                              

 

            Please list ANY health restrictions (including allergies) you feel should be called to our attention:

 

                                                                                                                                                                                                               

 

                                                                                                                                                                                                               

 

Can this information be shared with faculty                    

 

Please list all brothers and/or sisters below:

                                                                                DATE OF                                SCHOOL ATTENDING

NAME                                                                    BIRTH                     AGE        (if any)                                              GRADE

 

                                                                                                                                                                                                               

 

                                                                                                                                                                                                               

 

                                                                                                                                                                                                               

 

                                                                                                                                                                                                               

 

                Comments                                                                                                                               

 

                                                                                                                                                           

 

Date                                                                                                                                                    

                                                                        (Parent/guardian signature)