Student Record – North Wall Schools

For families with more than one child, please fill out and submit the form for each child.

Child’s Information:

First Name *
Last Name *
Birth Date *
Sex *
Ethnicity *
Class *
Address *
City *
State *
Zip Code *
Start Date *
Arrival Time *
Departure Time *

Other Information:

Referral to North Wall *
School District
School child will attend after North Wall *
Predicted date of final departure from North Wall Schools *
Does Child live with both parents?
If not, please specify *
Person responsible for payment of tuition *
Email Address for Billing *

Child’s Medical Information

Date of last physical (must be within one year):
Child’s Physician:
Physician Phone
Medical Insurance Provider
Policy Number *
Name of Insured *
Child’s Dentist *
Child’s Dentist Phone Number *
Allergies/Intolerances (Please List) *
Expected Symptoms *
Method of Treatment *
Life Threatening Conditions *
Current Medications *
Medical History *

Family

First Person for NW to contact: *
First Contact’s phone: *

Parent 1:

First Name *
Last Name *
Relationship to Child *
Address *
City *
State *
Zip Code *
Phone Number (Home)
Phone Number (Mobile)
Authorized to Pick up? *
Birth Date *
Place of Employment *
Job Title *
Work Phone *
Email Address *

Parent 2:

Siblings

#1

First Name
Last Name
Birth Date
School
Class
Authorized to pick up?

#2

First Name
Last Name
Birth Date
School
Class
Authorized to pick up?

#3

First Name
Last Name
Birth Date
School
Class
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

First Name
Last Name
Address (Within 30 miles of North Wall)
City
State
Zip Code
Place of Employment
Work Phone
Phone (Mobile)
Phone (Home)

#2

First Name
Last Name
Address (Within 30 miles of North Wall)
City
State
Zip Code
Place of Employment
Work Phone
Phone (Mobile)
Phone (Home)

#3

First Name
Last Name
Address (Within 30 miles of North Wall)
City
State
Zip Code
Place of Employment
Work Phone
Phone (Mobile)
Phone (Home)

#4

First Name
Last Name
Address (Within 30 miles of North Wall)
City
State
Zip Code
Place of Employment
Work Phone
Phone (Mobile)
Phone (Home)