PLEASE PRINT

YOUR NAME:______________________________________

ADDRESS: _________________________________________

HOME  PHONE: ____________________________________

I live with: (circle one)

Both Parents              Mom only            Dad only         OTHER: (specify) ________________

Mother's Full Name: __________________________________
Phone number where she can be reached during the day: ____________________________
E-mail address: ______________________________________

Father's Full Name: ___________________________________
Phone number where he can be reached during the day: _____________________________
E-mail address: ______________________________________

Other Guardian's Full Name: ____________________________
Phone number where he/she can be reached during the day: ___________________________

Emergency contact:  ___________________________________
Phone number where he/she can be reached during the day: ___________________________

YOUR CLASS SCHEDULE:

1st Hour ______________
2nd Hour______________    _____________    _______________    ________________
3rd Hour_______________    _____________    ______________    ________________
4th Hour_______________
5th Hour_______________
6th Hour_______________
7th Hour_______________

Extracurricular activities I'm involved in: (sports, band, etc)
_________________________________________________________________________
_________________________________________________________________________