Accokeek Academy Family Information Form 2022-2023
ALL INFORMATION MUST BE COMPLETED BY THE PARENT OR LEGAL GUARDIAN ONLY.
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Student's First Name *
Student's Middle Name
Student's Last Name *
Include suffix, if applicable.
Grade Level *
School Year 2022-2023
Name (Parent 1) *
Full Legal Name (First and Last)
Cell Phone Number (Parent 1) *
Format: xxx-xxx-xxxx
Home Phone Number (Parent 1)
Format: xxx-xxx-xxxx
Work Phone Number (Parent 1)
Format: xxx-xxx-xxxx
Email Address (Parent 1) *
Name (Parent 2)
Full Legal Name (First and Last)
Cell Phone Number (Parent 2)
Format: xxx-xxx-xxxx
Home Phone Number (Parent 2)
Format: xxx-xxx-xxxx
Work Phone Number (Parent 2)
Format: xxx-xxx-xxxx
Email Address (Parent 2)
List Siblings at Accokeek Academy
Name(s) and Grade Level(s)
1st Emergency Contact Name
1st Emergency Contact Relationship to Student
1st Emergency Contact Phone Number
Format: xxx-xxx-xxxx
2nd Emergency Contact Name
2nd Emergency Contact Relationship to Student
2nd Emergency Contact Phone Number
Format: xxx-xxx-xxxx
3rd Emergency Contact Name
3rd Emergency Contact Relationship to Student
3rd Emergency Contact Phone Number
Format: xxx-xxx-xxxx
Student is a *
If both, indicate the one that will occur more frequently. Indicate Van Rider if student will be picked up by an after-care program.
Student Medical Information - Does your child have a medical condition?  Please list all information about it that you think necessary for the school to know.  Please write N/A if there are none.
Student Medical Information - Does your child have food allergies?  Please name all foods and possible reaction and whether student has an Epi Pen? Please write N/A if there are none.
Throughout the school year, Prince George's County Public Schools (PGCPS) and the Prince George's County Board of Education conduct activities that may be publicized by local or national news media or used to promote the school system. Publicity activities include interviews, photographs or videos of individuals or groups of students, or studentworks(including, but not limited to, artistic works, athletic activities, performances and competitions) that may be used in websites, social media such as Facebook and Twitter,print or online publications, or videos.  Please check ONE of the two statements below. This Publicity Release Form will remain in effect through September 2023. *
Person Completing this Form *
First and Last Name
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