Date : _________________________________  

Student Name: _________________________________________________________________________

Phone #: ______________________________________________________________________________ 

Emergency Phone #: ____________________________________________________________________

Contact Person: ________________________________________________________________________

Relationship: ___________________________________________________________________________

Father's Name: _________________________________________________________________________

Mother's Name:_________________________________________________________________________

Actual Mailing Address:___________________________________________________________________

Give location of where you live (specify exact location):

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

School Attending: ________________________________________

Grade as of September 2002:_______________________________

Signature of Parent/Guardian: _____________________________________________________________