Student Information

Student Name (required)

Age (required)

Date of Birth (required)

Gender (required)
 Female Male

Home Address (required)

Does your child have allergies?
 Yes No

Please explain

Does your child have any medical or other conditions that we should be aware of?

Is your child taking any medications?
 Yes No

Please indicate what type(s)

Ethnicity
 African American Asian Caucasian Hispanic/Latino Native American Bi-Racial

Primary Language spoken in the home

Parent/Guardian Information

Parent/Guardian Name (required)

Home Address (required)

Home Phone (required)

Cell Phone

Email

Place of Employment/Attending School

Usual days/hours worked/attending class

2nd Parent/Guardian Name

Home Address

Home Phone

Cell Phone

Email

Place of Employment/Attending School

Usual days/hours worked/attending class

Emergency Contact

Name

Relationship to Student

Home Address

Home Phone

Cell Phone

Number of Adults living in home

Number of Children living in home

Please attach most W-2’s and Federal Tax Return. (To be used only to verify income eligibility)

Total Annual Household Income

Per Week

Is your child eligible for a free or reduced school lunch?
 Yes No

Do you rent an apartment or own home
 Rent Own

Please check if you receive
 Food Stamps Cash Assistance Unemployment SSI

Parent Photographic Release

I give permission for photos of my child to be used in New City School publications.
 I agree