| First Name | |
| Middle Name | |
| Last Name | |
| Preferred Name | |
| Gender | |
| Entering Grade | |
| Phone Number [ex. (901) 555-1234] | |
| Will student attend Central Learning Center after school care? | |
| T-Shirt Size | |
| PE Short Size (Gr. 6-8 only) | |
| Marital Status of Parents | |
| Student Lives With | |
| Parent/Guardian 1 First Name | |
| Parent/Guardian 1 Last Name | |
| Relationship to Student P/G1 | |
| Authorized to contact and pick up in an emergency P/G1 | |
| Parent/Guardian 1 Cell Number [ex. (901) 555-1234] | |
| Parent/Guardian 1 Email | |
| Parent/Guardian 1 Employer | |
| Parent/Guardian 1 Work Phone [ex. (901) 555-1234] | |
| Parent/Guardian 2 First Name | |
| Parent/Guardian 2 Last Name | |
| Relationship to Student P/G2 | |
| Authorized to contact and pick up in an emergency P/G2 | |
| Parent/Guardian 2 Cell Number [ex. (901) 555-1234] | |
| Parent/Guardian 2 Email | |
| Parent/Guardian 2 Employer | |
| Parent/Guardian 2 Work Phone [ex. (901) 555-1234] | |
| Doctor and Preferred Hospital (ex. Dr. Smith/Collierville Baptist) | |
| Student attends church | |
| Name of Church | |
| Emergency Contact 1 First Name | |
| Emergency Contact 1 Last Name | |
| Relationship to Student EC1 | |
| Authorized to pick up student EC1 | |
| EC1 Address | |
| EC1 City | |
| EC1 ST | |
| EC1 ZIP | |
| EC1 Home Phone [ex. (901) 555-1234] | |
| EC1 Cell Phone [ex. (901) 555-1234] | |
| EC1 Work Phone [ex. (901) 555-1234] | |
| EC1 Employer | |
| Emergency Contact 2 First Name | |
| Emergency Contact 2 Last Name | |
| Relationship to Student EC2 | |
| Authorized to pick up student EC2 | |
| EC2 Address | |
| EC2 City | |
| EC2 ST | |
| EC2 ZIP | |
| EC2 Home Phone [ex. (901) 555-1234] | |
| EC2 Cell Phone [ex. (901) 555-1234] | |
| EC2 Work Phone [ex. (901) 555-1234] | |
| EC2 Employer | |
| Emergency Contact 3 First Name | |
| Emergency Contact 3 Last Name | |
| Relationship to Student EC3 | |
| Authorized to pick up student EC3 | |
| EC3 Address | |
| EC3 City | |
| EC3 ST | |
| EC3 ZIP | |
| EC3 Home Phone [ex. (901) 555-1234] | |
| EC3 Cell Phone [ex. (901) 555-1234] | |
| EC3 Work Phone [ex. (901) 555-1234] | |
| EC3 Employer | |
| 1. Previous School Attended (if not applicable, skip to #5) | |
| 2. City, ST | |
| 3. Grades Attended | |
| 4. Reason for Leaving | |
| 5. Has student ever repeated a grade? | |
| Grade(s) |
|
| 6. Has student ever attended summer school or received tutoring? | |
| If so, please explain. | |
| 7. Has student ever had disciplinary difficulty in school? | |
| If yes, please list subjects. | |
| 8. Has student ever been recommended for special education? | |
| 9. Has student been diagnosed with a learning disability? | |
| 10. Has student been diagnosed with ADD or ADHD? | |
| 11. Has student had any childhood illnesses which might impair his/her ability to learn? | |
| If you answered YES to questions 8-11, please explain. | |
| 12. Does your child have any chronic medical conditions? | |
| 13. Has student been seriously ill? | |
| 14. Has student had an operation? | |
| 15. Has student had a serious accident? | |
| If you answered YES to questions 12-15, please explain. | |
| 16. Current Health Status (mark all that apply) |
|
| If you checked any of the medical conditions above, please explain. | |
| 17. Is student currently on any medications? | |
| If YES, please list what kind and for what reason. | |
| 18. Does student have any limitations relating to participation in physical education activities? | |
| If YES, please explain. | |
| 19. Does student wear any dental appliances? |
|
| 20. If student has experienced any event that might affect his/her well being, please explain. | |
| 21. Are the student's parents divorced or separted? | |
| If YES, please explain the custody agreement and living arrangements of student. | |
| 22. List this student’s special abilities, needs, talents and interests: | |
| 23. Please explain anything else you would like for the teacher to know about your child? | |