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Student Record

For families with more than one child, please complete the additional Child sections located at the bottom of the form.


CHILD: First Name: *
Last Name: *
Age: *
Birth Date: *
Sex: *
Schedule: Class *
Schedule: *
MEDICAL: Date of last physical (must be within one year): *
Child's Physician: *
Physician Phone: *
Medical Insurance Provider: *
Child's Dentist: *
Dentist Phone: *
Allergies/Intolerances (please list):
Current Medications:
Expected Symptoms:
Method of Treatment:
Life threatening condition:
Medical History:
CHILD/CHILDREN Address: *
City: *
State: *
Zip Code: *
Start Date: *
Arrival Time: *
Departure Time: *
Referral to North Wall: *
School District: *
School your child will attend after North Wall: *
Does this child live with both parents?: *
If not, please specify:
Predicted Date of Final Departure from North Wall Schools: *
Person responsible for payment of tuition: Name: *
Address: *
Phone: *
FAMILY: First Person for NW to contact: Name: *
Relationship to Child: *
Phone Number: *
Mother: First Name: *
Last Name: *
Home Phone: *
Authorized to pick up?: *
Address: *
If new: Address, City, State and Zip:
Birth Date: *
Place of Employment:
Job Title:
Address:
Work Phone:
Email Address: *
Cell Phone: *
Father: First Name: *
Last Name: *
Home Phone: *
Authorized to pick up?: *
Address: *
If new: Address, City, State and Zip
Birth Date: *
Place of Employment:
Job Title:
Address:
Work Phone:
Cell Phone: *
Email Address: *
Siblings: #1 Full Name:
Birth Date:
School:
Authorized to pick up?:
#2 Full Name:
Birth Date:
School:
Authorized to pick up?:
Birth Date:
#3 Full Name:
School:
Authorized to pick up?:
EMERGENCY CONTACTS: Persons (other than parents), to be contacted in an emergency, have access to health information, and authorized to pick up the child and transport him/her if parent cannot be reached. #1. Full Name: *
Home Phone: *
Address, City, State and Zip Code(must be within 30 miles of North Wall Schools): *
Place of Employment: *
Work Phone: *
Cell Phone: *
#2. Full Name: *
Home Phone: *
Address, City, State and Zip Code (must be within 30 miles of North Wall Schools): *
Place of Employment: *
Work Phone:
Cell Phone: *
#3. Full Name:
Home Phone:
Address, City, State, and Zip Code (must be within 30 miles of North Wall Schools):
Place of Employment:
Work Phone:
Cell Phone:
CHILD #2 : First Name:
Last Name:
Age:
Birth Date:
Sex:
Schedule Class:
Schedule:
MEDICAL: Date of last physical (must be within one year):
Child's Physician:
Physician Phone:
Medical Insurance Provider:
Child's Dentist:
Dentist Phone:
Allergies (please list):
Current Medications:
Expected symptoms:
Method of Treatment:
Medical History:
Life threatening condition:
CHILD #3: First Name:
Last Name:
Age:
Birth Date:
Sex:
Schedule Class:
Schedule:
MEDICAL: Date of last physical (must be within one year):
Allergies (please list):
Current Medications:
Expected Symptoms:
Method of Treatment:
Medical History:
Life threatening conditon: