Name _______________________________________________________  D.O.B. _______________

                      Last                                  First                          Middle

Grade/Teacher __________________Bus Number: ______Rides bus to:  HOME   OTHER ___________

Address ____________________________________________Home Phone # __________________

Custody:  (circle one)  Both Parents     Father     Mother   Other: ________________________________

Name of father/stepfather _________________________________Daytime Phone #_______________

Name of mother/stepmother _______________________________Daytime Phone #_______________

Only legal guardians should sign children out of school unless we are informed in writing.

Please list names of those who might at times be sent by you to check your child out of school.

1. ______________________________________ 2. _______________________________________

(May list additional names on back of card if necessary)

Are there custody concerns involving your child of which we should be aware?

YES _____   NO _________________(DESCRIBE ON BACK OF THIS CARD)

Who should be contacted first in the event that contact is necessary?  ____________________________

Emergency name and number other than above: _____________________________________________

Does your child have any physical and/or medical problems of which we need to be aware?

YES _____   NO  _________________ (DESCRIBE ON BACK OF THIS CARD)