Student Information Form
______________________ Student Information
Please submit a separate form for each student.
Student's First Name *
Your answer
Student's Last Name *
Your answer
Home Address *
Your answer
City, State and Zip *
Your answer
Home Phone
Your answer
Student's Cell Phone
It's good for us to have, "just in case."
Your answer
School Name *
Your answer
School Location
(neighborhood or address)
Your answer
Special Program, Major or Concentration
(if any)
Your answer
Student Birth Date
(required for minors only)
Your answer
Student's Grade Level *
(please pick one)
______________________ Medical Information
The health and safety of our students is important to us. Please provide any information that might be of concern.
Allergies *
Food, pets, medications: anything other than mild seasonal allergies. If none, please indicate: NONE
Your answer
Daily or Regular Medications *
Please indicate any regular medications, such as Ritalin, antihistamines or insulin, or any DAILY medications for chronic conditions. If none, please indicate: NONE
Your answer
Other Medical Conditions *
Please describe any medical condition that we should know about. If none, please indicate: NONE.
Your answer
______________________ Parent / Guardian Information
For adult students, please provide a contact for emergencies.
First Name *
Your answer
Last Name *
Your answer
e-mail address *
Your answer
Contact Type: *
(check all that apply)
Required
Relationship to student *
(check all that apply)
Required
Address *
Your answer
Cell Phone *
Your answer
Work Phone
Your answer
Home Phone
Your answer
______________________ Parent / Guardian #2
It's good to list a second contact.
First Name
Your answer
Last Name
Your answer
e-mail address
Your answer
Contact Type:
(check all that apply)
Relationship to student
(check all that apply)
Address
Your answer
Cell Phone
Your answer
Work Phone
Your answer
Home Phone
Your answer
______________________ Parent / Guardian #3
(Optional)
First Name
Your answer
Last Name
Your answer
e-mail address
Your answer
Contact Type:
(check all that apply)
Relationship to student
(check all that apply)
Address
Your answer
Cell Phone
Your answer
Work Phone
Your answer
Home Phone
Your answer
______________________ Anything Else?
Please let us know about anything else that we might need to know...
Your answer
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This form was created inside of Cobble Hill Think Tank.