Name (last, first MI) |
,
|
Lineage (Suffix) |
|
Nickname |
Home Phone |
|
Home Street |
Map |
Home city, state, zip |
,
|
Residency |
Expiration date of lease if Renting
|
Mailing Street |
Map |
Mailing city, state, zip |
,
|
Gender |
|
Student Number (PS#) |
|
Home Room |
|
SSN |
|
Birth date (mm/dd/yyyy) |
|
Directory Listing Permission |
|
Graduation Year |
|
Photo/Video Permission |
|
Reporting Ethnicity
|
Internet Use Permission |
|
|
PARENT/GUARDIAN
|
Lives With |
|
Mother's Name |
(Needs to be formatted like: Doe, John) |
Mother's Day Phone |
Cell Phone
|
Mother's Home Phone |
|
Mother's Email |
|
Mother's Employer |
|
Mother's Maiden Name |
(LAST NAME ONLY) |
Father's Name |
(Needs to be formatted like: Doe, John) |
Father's Day Phone |
Cell Phone
|
Father's Home Phone |
|
Father's Email |
|
Father's Employer |
|
Guardianship |
Single Parent Household
|
Guardian(Last, First, Middle) |
|
Guardian's Day Phone |
Cell Phone
|
Guardian Email |
(Separate multiple emails with commas, do not include any spaces) |
Guardian Alert Text |
|
EMERGENCY/MEDICAL INFO
|
Emergency Contact #1 |
|
Contact #1 Phone |
|
Contact #1 Relationship |
|
Phone Type
|
Emergency Contact #2 |
|
Contact #2 Phone |
|
Contact #2 Relationship |
|
Phone Type
|
Emergency Contact #3 |
|
Contact #3 Phone |
|
Contact #3 Relationship |
|
Phone Type
|
Doctor |
|
Doctor Phone#
|
Dentist |
|
Dentist Phone#
|
Medical Alert Text |
|
|