Please do NOT enter any area codes.
Student Data
Print neatly or circle response as appropriate!
Period: 1 2 3 4 5 6 7
Group Code: 1 2 I.D. #:
________
(semester
one only) (all year)
Lunch: A B C
Last: ___________________ First: ___________________ Middle:
___________________
Nickname: ___________________ (what your parents call
you)
Age: ________
Birth date:
/ /
Grade: 9 10 11 12
Sex: F M
Lives with: ________________________________(first name(s)) (last name(s))
Relationship: ___________________ (Parent or guardian or specify
other)
Street address: ________________________________ Zip: 777__
Home Phone (parents): ___________________
Home Phone (student): __________________________ Student Cell:
________________________
Father: ___________________Occupation: ___________________
Work Phone: ___________________ Employer: ___________________
Cell Phone: ___________________
Mother: ___________________ Occupation: ___________________
Work Phone: ___________________ Employer: ___________________
Cell Phone: ___________________
Camera owned (brand & model): ___________________
Computer owned (brand & model): ___________________
Video camera owned? 8mm VHS
Digital
Internet at home: Y or N
Student E-mail address: _______________________
Parents E-mail address: Father: __________________ Mother:
_______________________
What extracurricular activities are you involved in:
______________________________
Do you have a job, if so where and when: ___________________
This form is due back two days after receiving it.
Failure to return it on time may result in after-school teacher detention until
it is returned.
If you were missing this sheet, you were probably missing the back as well:
Student/Parent Agreement to Procedures and Permission to Use Equipment Form
