Early Bird Learning Center
Student Information Form 2014-2015
Today’s Date: ______Grade: ______Date of Birth: ______
______Age on Sept. 1 ______
Last Name (legal) First Name (legal) Middle Name (legal)
Student Physical Address: ______City/State/Zip: ______
Student Mailing Address: ______City/State/Zip: ______
LEGAL ALERT: ______
Ethnicity: (circle one for state reporting only):Native American Asian/Pacific Islander
Black/Non-Hispanic Hispanic
White/Non-Hispanic / Gender: M F
Social Security Number: ______-______-______
Home Language:______
Special Services: Has your child enrolled in any of the following classes or received any special services?
Speech ESL Bilingual Special EducationOther:______
1st Parent/Guardian: ______Relationship: ______
Address: ______City/State/Zip: ______
Home Phone: (______) ______Employer: ______
Cell phone: (______) ______Work phone: (______) ______
E-mail address: ______
2ndParent/Guardian: ______Relationship: ______
Address: ______City/State/Zip: ______
Home Phone: (______) ______Employer: ______
Cell phone: (______) ______Work phone: (______) ______
E-mail address: ______
Please list someone other than parents for emergency contact:
Emergency contact #1:______Phone: ______
Emergency contact #2:______Phone: ______
Please list someone other than parents authorized for student pick-up:
Contact #1:______Phone: ______
Contact #2:______Phone: ______
This enrollment form is a governmental record. The penalties for giving false information on governmental records are contained in section 37.10 of the Penal Code and in section 25.00(h) of the Texas Education Code. Any person who knowingly falsifies information to gain enrollment in AISD is liable for tuition fees (Texas Education Code 25.000).
Name of person enrolling child: ______Relationship: ______Date of birth: ______
Address: ______City/State/ZIP: ______
Health Information
Student: ______Grade: ______DOB: ______
Medical Conditions/History: ______
______
______
______
Current Medications: ______
______
______
Allergies (drug, food, insect, etc…):______
______
______
Please list all other siblings:
NameGradeCampus
______
______
______
______
______
Doctor Preference: ______Phone Number: ______
Hospital Preference:______Phone Number: ______
This is to certify that the above information is correct. I, the undersigned, do hereby authorize officials of the school to contact directly the person named on this form, and do authorize the above named physician to render such treatment as may deemed necessary in an emergency, for the health of said child.
In the event the physicians, other persons named on this form, or parents cannot be contacted, the school officials are hereby authorized to take whatever action is deemed necessary in their judgment, for health of said child.
I will not hold the school district financially responsible for the emergency care and/or transportation of said child.
Parent/Guardian Signature: ______Date: ______