STUDENT DATA
Date ______________
Child’s Full Name ___________________________________________________________________
(Nickname ____________________________)
Birthdate _______________________
Home Address _______________________________________________________________________
Zip Code __________________
Mother or Guardian’s Name ______________________________________
Address (if different from child’s) __________________________________
Employed _______________________________________
Business Phone __________________________
Home Phone __________________________
Father or Guardian’s Name ______________________________________
Address (if different from child’s) __________________________________
Employed _______________________________________
Business Phone __________________________
Home Phone __________________________
EMERGENCY NUMBERS
Persons other than parents to be contacted in case of emergency
Name ____________________________
Phone __________________
Name ____________________________
Phone __________________
Persons not permitted to call for child: _________________________________________________
Chronic or handicapping problem i.e. allergies, drug reactions, etc. and special instructions
regarding such problems:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Identification and Emergency Information
Counterpoint School
To Be Completed by Parent or Guardian:
Child’s Name:
Address:
Last:
Number:
Middle:
First:
Street:
City:
Sex:
State:
Zip:
Birthdate:
Home Telephone:
(
Father’s Name:
Last:
Middle:
First:
Cell Phone:
(
Address:
Number:
Street:
City:
State:
Zip:
Last:
Middle:
First:
Number:
Street:
City:
State:
Zip:
Middle:
First:
)
Business Telephone:
(
Person Responsible for Child: Last Name:
)
Cell Phone:
(
Address:
)
Business Telephone:
(
Mother’s Name:
)
)
Cell Phone:
Business Telephone:
(
(
)
)
Additional Persons Who May be Called in an Emergency:
Name:
Address:
Telephone:
(
)
(
)
(
)
(
)
Relationship:
Physician or Dentist to be called in an Emergency:
Physician:
Address:
Medical Plan and Number:
Dentist:
Address:
Medical Plan and Number:
Telephone:
( )
Telephone:
( )
If Physician cannot be reached, what action should be taken?
_____ Call Emergency Hospital
_____ Other
Explain: _____________________________________________
Names of persons authorized to take child from the facility:
(Child will not be allowed to leave with any other persons without written authorization from parent or guardian)
Name:
Address:
Telephone:
(
)
(
)
(
)
(
)
Relationship:
Time your child will be called for: _____________________________________________________________________________________________________
Signature of Parent or Guardian: ___________________________________________ Date: ___________________________________
To be completed by Counterpoint School Director/Administrator
Date of Admission:
Date Left: