INITIAL STUDENT DATA REGISTRATION

(PLEASE PRINT)

Student’s Name ___________________________________________ Registration Date ___ / ___ / _____

Last First MI
Address ____________________________________________________________________________
City ___________________________________ State ____________________ ZIP_______________
Home phone ______________ Cell Phone ________________ Social Security # _____ - ___ - ____
Date of birth ____ / ____ / ____ Age ______ Grade ____

Last School Attended:

School Name_______________________________________ Phone (______) ______ - _________

Address ____________________________________________________________________________
City ____________________________________ State ___________________ ZIP______________

Father’s name _________________________________________________ Living with student? _______

Address ____________________________________________________________________________
City ________________________________ State ____ Zip _______Home Phone ________________
Work phone (______) ______ - __________ Cellular phone/Pager/Etc. (______) ______ - ___________

Mother’s name _______________________________________________ Living with student? __________

Address _____________________________________________________________________________
City ________________________________ State ____ Zip _______ Home Phone ________________
Work phone (______) ______ - __________ Cellular phone/Pager/Etc. (______) ______ - ____________

Alternate Contact (Name) _______________________________ (Relationship)_______________________

Home Phone____________________ Work Phone_________________ Cell Phone________________

Emergency Contact (Name) ________________________________ (Relationship)_____________________

Home Phone____________________ Work Phone__________________ Cell Phone________________

For Administrative Use Only:

Official Registration Date _____/ _____/ _____ Official Lottery Date _____/ _____/ _____

2010-11