Pupil Information Change Form
Legal Name: First
Middle Name
Last Name
Social Security Number
Address and Apartment Number
Date of Birth
City
Zip Code
Place of Birth
Phone Number
Please enter a valid phone number.
SEX (M or F)
Race
Who has Legal Custody of Child
PARENT / GUARDIAN INFORMATION: PLEASE COMPLETE FOR EACH PARENT OR GUARDIAN
Parent or Guardian 1
Parent or Guardian 1 Information
Relationship
Home Telephone with Area Code
Work Telephone and Extension
First Name
Middle Name
Last Name
Address
City
Zip Code
Employer
Occupation
Parent or Guardian 2
Parent or Guardian 2 Information
Relationship
Home Phone (with Area Code
Work Telephone and Extension
First Name
Middle Name
Last Name
Address
City
Zip
Employer
Occupation
EMERGENCY CONTACT 1
Emergency Contact Information
Relationship
Home Telephone with Area Code
Work Telephone with Area Code
First Name
Middle Name
Last Name
Emergency Contact 2
Type a question
Relationship
Home Telephone with Area Code
Work Telephone with Area Code
First Name
Middle Name
Last Name
FAMILY INFORMATION _ PLEASE LIST ALL BROTHERS AND SISTERS aged to 4 to 18
First Brother or Sister
Last Name
First Name
Sex
Date of Birth
ID Number
Second Brother or Sister
Last Name
First Name
Sex
Date of Birth
ID Number
Third Brother or Sister
Last Name
First Name
Sex
Date of Birth
ID Number
Fourth Brother or Sister
Last Name
First Name
Sex
Date of Birth
ID Number
Fifth Brother or Sister
Last Name
First Name
Sex
Date of Birth
ID Number
Sixth Brother or Sister
Last Name
First Name
Sex
Date of Birth
ID Number
Who does the student live with?
Student lives with (check one)
Both Parents
Father Only
Mother Only
Father & Stepmother
Mother and Stepfather
Foster Parents
Legal Guardian
Institution
Other
Self
Current School and Grade
Grade
School
I certify that the information above is true and correct
Clear
Date
-
Month
-
Day
Year
Date
I hereby give consent for medical treatment
Clear
Date
-
Month
-
Day
Year
Date
Please attach proof of residence document(s)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Preview PDF
Submit
Should be Empty: