CTLA Student and Parent Contact Information
(Please use correct upper/lowercase letters and punctuation)
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Student First Name *
Student Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Grade Level 2021-22 *
Student's Address *
(please include city, state, and zip code)
Student's Mailing Address (if different than above; please put N/A if this does not apply) *
Student's Cell Phone Number (please put N/A if this does not apply) *
Student's E-mail Address ending with @jcsnc.org *
Mother or Guardian's Name (please put N/A if this does not apply) *
Mother or Guardian's Address (if different from student)
Mother or Guardian's Home Phone Number (please put N/A if this does not apply) *
Mother or Guardian's Cell Phone Number (please put N/A if this does not apply) *
Mother or Guardian's Work Phone Number (please put N/A if this does not apply) *
Mother or Guardian's E-mail Address (please put N/A if this does not apply) *
Father or Guardian's Name (please put N/A if this does not apply) *
Father or Guardian's Address (if different from student)
Father or Guardian's Home Phone Number (please put N/A if this does not apply) *
Father or Guardian's Cell Phone Number (please put N/A if this does not apply) *
Father or Guardian's Work Phone Number (please put N/A if this does not apply) *
Father or Guardian's E-mail Address (please put N/A if this does not apply) *
Emergency Contact Person's Name (other than parent or legal guardian) *
Emergency Contact Person's Home Phone Number (please put N/A if this does not apply) *
Emergency Contact Person's Cell Phone Number (please put N/A if this does not apply) *
What is your means of transportation to and from school?
Clear selection
Please list names of people who have permission to pick up student from school. *
Please list names of people who DO NOT have permission to pick up student from school. (please put N/A if this does not apply) *
Student's Medical Concerns/Needs (please put N/A if this does not apply) *
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