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The Eddy School

8 Bear River Road

Newry, ME 04261

(207) 381-7716

www.TheEddySchool.com

www.facebook.com/The.Eddy.School

Deb Webster, Director

TheEddy2011@gmail.com

2018-2019 GENERAL INFORMATION FORM

Student:

Last________________________ First______________________Middle_________________

Nickname: ________________________________________________

Birth date: ________________________________________________

Gender □M □F

Applicant’s Present Grade:____________________________________

Applicant’s Present School District:______________________________

Names of Parent(s) or Guardian(s): ___________________________________________________________________________

Student lives with: □both parents □ father □ mother □ joint custody

Contact Information for Parent(s)/Guardian(s):

Street or P.O. ______________________________________________

City ______________________________ State _____ Zip __________

Father email:________________________________________________________________

Mother email:________________________________________________________________

Father phone(s): _____________________________________________________________

Mother phone(s): _____________________________________________________________

Grandparent Contact Information:

(paternal) Name:______________________   (maternal) Name: _______________________

mailing address: ______________________                                       ______________________

                       ______________________                            ______________________

email addresses: _______________________                            ______________________

                       _______________________                            ______________________

Health Information:

Does the applicant have any physical or health problems requiring special attention? □yes □no

If yes, please explain in detail in writing and attach to this application.

Prescribed Medication(s):_____________________________________________________

Learning Disability(ies):______________________________________________________

In accordance with Federal Law and USDA Policy, this school does not discriminate on the basis of race, color, national origin, sex, age or disability (not all prohibited bases apply to all programs).