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Child's Last Name	Child's First Name	Child's Middle Name
Name Child Goes by	Male Female
Address Street/Apt.	City/State	Zip
Date of Birth (mm/dd/yyyy)	Grade in school	Home Phone
Mother's Name	Work/Cell Phone
Father's Name	Work/Cell Phone
Parent E-mail Address
PLEASE NOTE ANY SPECIAL SITUATIONS THAT TEACHERS SHOULD BE AWARE OF:
Allergies:
Learning Differences:
My child would benefit from an adult "buddy" in the classroom. Please call me.
Shared Custody With:
Name	Relationship	Phone
Other
Enroll my child for (select all that apply): multiple selections may be made by holding down the "Ctrl" key
Friend-Focus. Name one friend to be placed in same class. We will do our best to accommodate requests.
I give permission for my child to be released to the following individuals:	Relationship to child:



My child is in 4th grade or above and has my permission to leave unescorted when class is dismissed.
Permission is is not (check one) given to use my child's photo in publications, including website.