Last Name

First Name

Middle Name

Birth Date

Place of Birth

Social Security #

Nationality

Age

Address

Student Lives With Student Lives WithMother and FatherMother OnlyFather OnlyGuardian

Religion ReligionNazareneOther

Did student attend preschool? Did student attend preschool? yes no

If yes, name the preschool

Has student received all immunization? Has student received all immunization? yes no

Is the student a transfer? Is the student a transfer? yes no

Name of School Transferring from

Grade last attended Grade last attendedNot ApplicablePreschoolInfant OneInfant TwoStandard OneStandard TwoStandard ThreeStandard FourStandard FiveStandard Six

Grade Admitted to Grade Admitted toPreschoolInfant OneInfant TwoStandard OneStandard TwoStandard ThreeStandard FourStandard FiveStandard Six

Any health conditions the school should be aware of?

Does the student ride the bus to school? Does the student ride the bus to school? yes no

Father's Name

Father's Nationality

Mother's Name

Mother's Nationality

Name of person responsible to pay bills

Name of person responsible to pick up student

Contact Number