Student Data Collection form.xlsx
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STUDENT DATA COLLECTION FORM
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PRENTICE SCHOOL DISTRICT
Prentice School Dist-
Ogema
Prentice Ele
Prentice HS
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Date: / /
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STUDENT DATA:
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LEGAL LAST NAME______________________________LEGAL FIRST NAME_____________________________LEGAL MIDDLE NAME___________________________
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GENDER
MALE
FEMALE
BIRTHDATE_____/____/_____
GRADE_____________
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SOCIAL SECURITY NUMBER________-________-_________
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ADDRESS_________________________________________________________________________________________
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STREETPO BOX
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CITY____________________________________________ZIP___________________________
City
township
village
of_______________________
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ETHNICITY Black Hispanic
American Indian
white Asian
(check all that apply)
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Does this child have any serious health conditions?
No
Yes-list below
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________________________________________________________________________________________________________________________________________
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Does this child have any serious learning disabilities?
No
Yes-list below
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________________________________________________________________________________________________________________________________________
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Other Children Data
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Please list all siblings that currently reside in the same home as this student who are 20 years of age or younger:
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Name________________________________________Relationship____________________________________________DOB________________________________
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Name________________________________________Relationship____________________________________________DOB________________________________
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Name________________________________________Relationship____________________________________________DOB________________________________
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Name________________________________________Relationship____________________________________________DOB________________________________
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Name________________________________________Relationship____________________________________________DOB________________________________
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Name________________________________________Relationship____________________________________________DOB________________________________
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Name________________________________________Relationship____________________________________________DOB________________________________
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Parent/Guardian Data
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Status of parents
married
Father deceased
Mother deceased
separated
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divorced
custody is joint
custody is sole -name_________________________
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Who has primary physical placement of the child during school hours?_________________________
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NOTE- In cases where both biological/legal parents are alive but are separated or divorced, it is important that we have the
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data for all parental adults. Future school mailings will be sent to both adults/households unless we are informed otherwise.
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First set of Parents-
check if child lives here
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Parent 1 (The adult who is filling out this form should be listed first.)
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last name_______________________________________________
first name___________________________________
Middle_______________________________
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Relationship
mother
Father
step-mother
step-father
Foster Mother
Foster Father
guardian
other___________
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Address________________________________________________________________________________________________
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Home phone_________________________cell phone_____________________________________
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Email______________________________________________________________________________
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Employer_________________________________________________________________________
Work Phone________________
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Parent 2
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Last name_____________________________________________
first name________________________________
Middle_____________________
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Relationship
Mother
Father
Step-mother
Step-father
Foster Mother
Foster Father
guardian
other__________
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Address__________________________________________________________________________________________
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Home phone_________________________Cell phone_____________________________________
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Email______________________________________________________________________________
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Employer_________________________________________________________________________
Work Phone________________
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Second set of Parents-
check if child lives here
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Parent 3
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Last name___________________________________________
first name________________________________
Middle_____________________
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Relationship
Mother
Father
Step-mother
Step-father
Foster Mother
Foster Father
guardian
other___________
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Address________________________________________________________________________________________________
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Home phone_________________________cell phone_____________________________________
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Email______________________________________________________________________________
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Employer_________________________________________________________________________
Work Phone________________
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Parent 4
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Last name_____________________________________________
first name________________________________
Middle_____________________
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Relationship Mother Father
Step-mother
Step-father
Foster Mother
Foster Father
guardian
other__________
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Address__________________________________________________________________________________________
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Home phone_________________________Cell phone_____________________________________
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Email______________________________________________________________________________
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Employer_________________________________________________________________________
Work Phone________________
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EMERGENCY
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Primary contact
DAYTIME #
Relationship
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_______________________________________
____________________
__________________________
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Secondary contact
DAYTIME #
Relationship
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_______________________________________
____________________
___________________________
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Approximate distance from home to school in miles______________________
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Family Physician_______________________________________________Phone_____________________
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Family Dentist_________________________________________________Phone_____________________
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Signature
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_____________________________________________________date / /
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If an emergency exists, I hereby authorize school employees to obtain the services of a local physician or dentist for the child named on this form
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