2009-2010 Registration

Please note that registration is not complete
until payment is received.

1st Student Name

First Name

Middle Name

Last Name

Date of Birth (Month-Day-Year)

Student 1 - Grade

Social Security #

2nd Student Name

First Name

Middle Name

Last Name

Date of Birth (Month-Day-Year)

Student 2 - Grade

Social Security #

3rd Student Name

First Name

Middle Name

Last Name

Date of Birth (Month-Day-Year)

Student 3 - Grade

Social Security #

4th Student Name

First Name

Middle Name

Last Name

Date of Birth (Month-Day-Year)

Student 4 - Grade

Social Security #

Home Contact

Parent First Name

Parents Last Name

Parents Street Address

Parents City

Parents State

Parents Zip

Parents County

Home Phone

Work Phone 1

Cell Phone 1 -

Work Phone 2 -

Cell Phone 2 -

Emergency Housing

Used if student can not make it home due to weather.

First Name

Last Name

Street Address

Address Line 2

City

State

Phone Number 1

Phone Number 2

Daytime Contact #1

Emergency contact when parents can not be reached during the day. Contacts will be asked to assume responsibility in case of emergency and take your child home if she/he becomes ill or other problem arises.

First Name

Last Name

Street Address

Address Line 2

City

State

Phone Number 1

Phone Number 2

Daytime Contact #2

First Name

Last Name

Street Address

Address Line 2

City

State

Phone Number 1

Phone Number 2

No Pickup

The above person(s) should NEVER be allowed to pickup my student.

Name(s) and relationship:

Non-Custodial

The following person should get a copy of student grades and other letters of interest.

First Name

Last Name

Street Address

Address Line 2

City

State

Zip Code

Phone Number

Indicates Response Required