STUDENT INFORMATION SHEET

PLEASE PRINT ALL INFORMATION LEGIBLY.
NAME ____________________________ , __________________________ , ______
                            (LAST)                                        (FIRST)                          (MI)

PREFERS TO BE CALLED ___________________    BIRTHDAY __________________

YOUR E-MAIL ADDRESS  _________________________________________________

ADDRESS _____________________________________________________________

               _____________________________________________________________

HOME PHONE NUMBER ______________________________
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PARENTS OR LEGAL GUARDIANS (Please put a star in front of the parent(s) you live with)

_ FATHER _________________________        _ MOTHER _________________________

E-MAIL ___________________________       E-MAIL ____________________________

HOME PHONE # ____________________        HOME PHONE # _____________________
                          (if different from above)                                 (if different from above)

CELL PHONE # _____________________        CELL PHONE # ______________________

WORK PHONE # ____________________        WORK PHONE # _____________________
                         (only used if emergency)                                 (only used if emergency)
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EXTRACURRICULAR ACTIVITIES
JOB? __ YES  __ NO      IF YES, WHERE? ___________________________ HRS./WK. _____

SPORTS, ACTIVITIES, HOBBIES, CLUBS __________________________________________
___________________________________________________________________________
GRADE _____                AGE ____            CMS ID # ____________________           
1ST PD. TEACHER ________________________
2ND PD. TEACHER _________________________
MOST RECENT SCIENCE CLASS TAKEN __________________________________________
CURRENT MATH CLASS ______________________________________________________
HOW DID YOU DO IN ALGEBRA I?  _____________________________________________
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MEDICAL INFORMATION (confidential - only used in case of an emergency)
DOB _______________        BLOOD TYPE _______________

DO YOU WEAR CONTACT LENSES? _________

CHRONIC HEALTH PROBLEMS/PHYSICAL DISABILITIES _____________________________
__________________________________________________________________________

CURRENT MEDICATION(S) ____________________________________________________

ALLERGIES/ALLERGIES TO MEDICATIONS ________________________________________
___________________________________________________________________________

PERSONAL PHYSICIAN __________________________________ PHONE # ____________

EMERGENCY CONTACT (other than family member)

NAME ____________________________    HOME PH. # ____________________________

CELL PH. # ________________________    WORK PH. # ____________________________
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QUESTIONS - ANSWER THESE IN DETAIL.  NO NEED FOR COMPLETE SENTENCES!

1.  What are your goals when you graduate from high school?  Be specific.  Instead of saying, "get a job", explain what job it is you want and how you are going to achieve those goals.

 

 

2.  What activities/projects/types of instruction really help you learn?  Think about this.  Don't just put down situations in which you had fun!  Under what circumstances do you learn a lot?

 

 

3.  What is the most important event that has ever happened in your life?  This could be a good or bad event.  How did this event change you?

 

 

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