George-Little Rock School

GEORGE-LITTLE ROCK SCHOOL 2017-2018

FAMILY INFORMATION:

1. Father/Guardian: ______Married:____Single:____Divorced:____Separated:_____

PO Box & Street Address: ______

City, State, Zip: ______Home Phone: ______

Work Phone: ______Extension: _____ 800 #______Employer:______

Cell Phone: ______E-Mail: ______

Military Status: Active: ___Yes ___No Deployed: ___Yes ___No Branch: ______

2. Mother/Guardian: ______Married:____Single:____Divorced:____Separated:____

Address: (PO Box & Street) ______

City, State, Zip: ______Home Phone: ______

Work Phone: ______Extension: _____ 800 #______Employer:______

Cell Phone: ______E-Mail: ______

Military Status: Active: ___Yes ___No Deployed: ___Yes ___No Branch: ______

Children Living With: (Check One) ___1-Both Parents ___2-Mother Only ___3-Father Only ___4-Self

___5-Agency ___6-Guardian ___7-Mother/Stepfather ___8-Father/Stepmother ___9-Stepfather/Stepmother

___0-Other (Specify)

EMERGENCY INFORMATION:

To serve your child in case of Accident or Sudden Illness, it is necessary that you furnish the following information for emergency calls. List two neighbors or nearby relatives who will assume temporary care of your child if you cannot be reached:

1. Contact Name: ______Home Phone: ______

Address: ______City, State: ______

Work Phone: ______Cell Phone: ______

2. Contact Name: ______Home Phone: ______

Address: ______City, State: ______

Work Phone: ______Cell Phone: ______

3. Doctor: ______Phone: ______

Doctor: ______Phone ______

4. Dentist: ______Phone: ______

Hospital Choice: ______Phone: ______

Address: ______

MEDICAL:

List any Health Conditions/Allergies/Medications:

Name: ______Conditions/etc.: ______

In the event that my child may require medical attention and I am unable to be reached, I hereby give my consent to medical treatment to the GEORGE-LITTLE ROCK SCHOOL and Doctor/Dentist, or his or her designee to provide this care. I agree to pay all the costs and fees contingent on any emergency medical care and/or treatment for my child as secured or authorized under this consent. ___ Yes ___ No

Signature: ______(Every effort will be made to notify parents (Guardian) immediately in case of emergency)

STUDENT INFORMATION: (List all children in the family)

1. Name: ______Grade: _____ Ethnicity: ______

Birthdate: ______Sex: ______Birthplace: ______

Social Security Number: ______Race: ______

2. Name: ______Grade: _____ Ethnicity: ______

Birthdate: ______Sex: ______Birthplace: ______

Social Security Number: ______Race: ______

3. Name: ______Grade: _____ Ethnicity: ______

Birthdate: ______Sex: ______Birthplace: ______

Social Security Number: ______Race: ______

4. Name: ______Grade: _____ Ethnicity: ______

Birthdate: ______Sex: ______Birthplace: ______

Social Security Number: ______Race: ______

PARENTAL/GUARDIAN CONSENT FORM:

_____ Yes _____ No 1. My child/children have permission to have breakfast.

_____ Yes _____ No 2. My child/children have permission to have ala-carte items.

_____ Yes _____ No 2. My child/children have permission to take the school-sponsored trips throughout the year for which a note will be sent home informing me of such field trips before they occur.

_____Yes ______No 3. I give permission to use photographs of my child/children participating in school and/or school related programs and activities for the purpose of public relations.

_____ Yes _____ No 4. My child/children have permission to be released to the emergency contacts on the reverse side if I cannot be reached.

____ Yes _____ No 5. I give permission for the following persons named below to pick up my child/children. It is the responsibility of the parents to notify the school in writing of any changes.

1. ______2. ______

3. ______4. ______

______is not allowed to pick up my child/children.

Parent Signature: ______Date: ______