Student Name: _________________________________________________________________________

Date of Birth: _________________________________  Age:_____________________________________

Father's Name: ________________________________ Mother's Name:____________________________

Place of Residence: ____________________________________________ Phone:  __________________

Father's Occupation: _____________________________________________________________________

Address: _____________________________________________________  Phone: __________________

Last year of school completed: HS     1      2      3      4                     College: 1      2      3      4+

Mother's Occupation : _____________________________________________________________________

Address: _____________________________________________________  Phone: __________________

Last year of school completed: HS     1      2      3      4                     College: 1      2      3      4+

Previous Places of residence (in order): ____________________________________________________

_____________________________________________________________________________________

 Brothers and sisters living at home (list names/birthdates): ___________________________________

_____________________________________________________________________________________

 Please list other persons in household:  __________________________________________________

_____________________________________________________________________________________

 If the parent is not available in case of emergency, please call:

1. Name: __________________________________________  Phone: ___________________________

2. Name: __________________________________________  Phone: ___________________________

Entering Date: ______________________________________ Bus Route: ________________________

Birth Certificate furnished: _____________________________ Pupil's Sex: _______________________