Student Demographic Form SY 17-18
Please provide all required information so it may be properly documented in TCGDC's system.
STUDENT INFORMATION
Student 1 Last Name *
Your answer
Student 1 First Name *
Your answer
Student 2 Last Name *
Your answer
Student 2 First Name *
Your answer
Student 3 Last Name
Your answer
Student 3 First Name
Your answer
Student 4 Last Name
Your answer
Student 4 First Name
Your answer
Student 5 Last Name
Your answer
Student 5 First Name
Your answer
PARENT/GUARDIAN INFORMATION AND OTHER PRIMARY CAREGIVER INFORMATION*
1. Parent or Guardian Last Name *
Your answer
Parent or Guardian First Name *
Your answer
Relationship *
Your answer
Primary Number *
Your answer
Cell Number *
Your answer
Work Number *
place NA if not applicable
Your answer
2. Parent or Guardian Last Name *
Your answer
Parent or Guardian First Name *
Your answer
Relationship *
Your answer
Primary Number *
Your answer
Cell Number *
Your answer
Work number *
Your answer
IN CASE OF EMERGENCY
1. Emergency Contact Person (other than parent/guardian) *
Your answer
Relationship *
Your answer
Primary Number *
Your answer
Cell Number *
Your answer
Work Number
Your answer
Can your child be released to this person? *
2. Emergency Contact Person (other than parent/guardian) *
Your answer
Relationship *
Your answer
Primary Number *
Your answer
Cell Number *
Your answer
Work Number *
Your answer
Can your child be released to this person? *
Signature, Date, and Certification of Accuracy
* TCGDC agrees that the data/information provided in the Student Enrollment Form remain confidential and shall only be used for legitimate TCGDC business.
I completed this form and I certify that the information above is accurate. I understand that providing false information for purposes of defrauding the government is punishable by law. Form should not be signed prior to April 3. Information provided on this form should be applied consistently throughout enrollment documentation. *
Typed name acts as the signature of the Parent/Guardian with whom the student lives
Your answer
Person Completing This Form Is: *
Submission Date *
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