Student Information Card
First Name *
Your answer
Last Name *
Your answer
Middle Name or Initial
Your answer
Nickname (What the student goes by)
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Race
Grade *
Teacher
What Is the Student's Home School District *
Is the Student Currently Receiving Special Education Services *
Number and Street Address *
Your answer
City *
Your answer
Zip Code *
Your answer
Student Contact Information
Please enter your contact and emergency contact information in priority order (Contact 1 should be the primary correspondence while Emergency Contact 2 will be the last person we will call to contact you)
Email Address (required; for school and teachers for correspondences) *
Your answer
Secondary Email Address (not required)
Your answer
Contact 1 First and Last Name (Legal Guardian)
Your answer
Contact 1 Relationship to Student
Your answer
Contact 1 Contact Phone Number (xxx)xxx-xxxx
Your answer
Contact 1 Contact Secondary Phone Number (xxx)xxx-xxxx
Your answer
Contact 2 First and Last Name
Your answer
Contact 2 Relationship to Student
Your answer
Contact 2 Contact Phone Number (xxx)xxx-xxxx
Your answer
Contact 2 Contact Secondary Phone Number (xxx)xxx-xxxx
Your answer
Who Does the Student Reside With
Your answer
Do both Natural Parents Live in the Home
If No, Please Provide the Name and Address of Natural Parent and Stepparent that the Student Does Not Reside With
Your answer
If Both Natural Parents Do Not Reside Together, Has a Court Order Been Entered with Regard to Custody of the Child(ren)?
Custodial Concerns (pending proof, please describe your situation and custody agreement)
Your answer
Are There Any Restrictions on Who Picks Up the Student From School? (Yes, Name)
Your answer
Is this Supported by a Court Order
1st Emergency Contact Authorized to Act for the Parents in Case of Emergency First and Last Name (will be contacted if neither contact 1 or 2 is available)
Your answer
1st Emergency Contact Primary Phone Number
Your answer
1st Emergency Contact Secondary Phone Number (if applicable)
Your answer
1st Emergency Contact Relationship to Student
Your answer
1st Emergency Contact Can Pick Up the Student
2nd Emergency Contact Authorized to Act for the Parents in Case of Emergency First and Last Name
Your answer
2nd Emergency Contact Primary Phone Number
Your answer
2nd Emergency Contact Secondary Phone Number (if applicable)
Your answer
2nd Emergency Contact Relationship to Student
Your answer
2nd Emergency Contact Can Pick Up the Student
Student Medical Information
The following information will be accessible by the school nurse and BCMCS data personnel. Pertinent information will be relayed to other staff when applicable.
What Significant Medical History or Medications Does Your Student Have/Take
Your answer
Child's Physician
Your answer
Office Phone Number
Your answer
Over the Counter Medicine Administration
The School Nurse MAY Administer My Student
Has Your Child Ever:
Please respond with No or Yes, followed by a date and explanation
Been Seriously Ill?
Your answer
Had an Operation
Your answer
Had any Serious Accident
Your answer
Please Check Any Current Health Concerns
Student Is Allergic To:
If checked, please expand upon the nature of the condition/s or reaction
Your answer
Please Note
Please note: All life threatening health conditions/allergies and significant
asthma conditions require a health care plan prior to attending school.
Any Medications? (With Dosage Amount)
Your answer
Are There Any Physical Limitations Teachers Should Be Aware Of?
Your answer
School Health Authorization
I authorize a BCMCS official to contact directly the persons named on this form. In the event parents, physician, or other
persons cannot be contacted, I authorize BCMCS to take whatever action necessary for my child's health indicated by my digital signature below.
Parent Signature (First Last)
Your answer
Affirmation of Prior Discipline Record
Pennsylvania School Law 1304-A

Prior to admission to any school, the parent, or guardian, or other person having control or charge of a student, shall upon registration, provide a sworn statement or affirmation stating whether the pupil was previously suspended or expelled from any public or private school of this Commonwealth or any other State for an act or offense involving weapons, alcohol, or drugs, or for the willful infliction of injury to another person or for any act of violence committed on school property, at a school sponsored activity or on a public or private conveyance providing transportation to or from school or a school sponsored activity.

I have read the above paragraph and affirm that my student _____ been suspended or expelled
Fill out the following if you have selected 'Has' in the previous question
Name of school which the student was suspended or expelled
Your answer
Dates of suspension or expulsion (please provide all dates mm/dd/yy, mm/dd/yy etc)
Your answer
Reason for suspension/expulsion
Your answer
Student Discipline Authorization
(Any willful false statement made above shall be a misdemeanor of the third degree.This form shall be maintained as part of the student’s disciplinary record. 24 P.S. §13-1317-2)
Parent Signature (First Last)
Your answer
Home Language Survey
What language did the student learn first?
What language does the student speak most of the time?
Which language does the student use most often when he/she speaks to his/her parents?
Audio/Video/Photo/Directory Waiver Release Form
To protect the privacy and safety of Bucks County Montessori Charter School students, personal information about student (such as student home addresses, e-mail addresses and phone numbers) will not be published on any BCMCS web page or disseminated to any organizations or media outlets under any circumstances. Class directories, which include student name, address and phone number are available should you choose to have your child included. These directories are only disseminated to students within the same home room.

Student names, photos of students, audio or video recordings of students and/or student work may be published on official school newsletters or web pages, or shared with school approved news media, organizations or web services, with parent permission below.

Please note that no permission is required for large group photos in which the students are not individually identified.

Release

I hereby grant Buck County Montessori Charter School the right to use and reproduce any and all photographs, video clips, and/or audio clips taken of my child in conjunction with their involvement at BCMCS in any school newsletters, brochures, web sites, flyers and publications, or any outside school approved publications such as newspaper, magazines, web sites promoting the school or reporting on activities associated with the school.

I waive the right to inspect or approve the finished version(s) of such images including written copy that may be created in connection therewith.

Consent is also granted for any use of my child’s name in any part of those publications listed above.

I understand that photos/audio/video used by the school for the reasons stated above, are considered the property of Bucks County Montessori Charter School and may not be sold or reused without the express consent of school officials or administration.

I understand that there is no monetary compensation for use of my child’s image and that this waiver/release is good for the entire time that my child is enrolled at the school.

I have read this document and am fully aware of the consent and implications, legal, and otherwise.

This is to certify that I, as parent/guardian with legal responsibility for this student
Media Authorization Release
In accordance with the answers above
Parent Signature for Release (First Last)
Your answer
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