TEACHER'S INFORMATION

Age Sept. 1st_____________                        Birth Date______________

Child's Name

____________________________________________________________
Last                        First                        Middle                        Name called

Parents' Names

________________________________________________________

Residence Address

________________________________________________________

Mailing Address

__________________________________________________________

Home Phone                           Work Phone  _______________________

 List below the person or persons authorized to pick up your child in case you cannot.

1._________________________________________________________________
                        (Name)                        (Address)                        (Phone Number)

2.__________________________________________________________________
                        (Name)                               (Address)         (Phone Number)

Which of the following would you be able to do?
 __________Drive a car and help with a field trip         __________Other (explain)

     __________ Help with a party               __________None

End of Form

Updated Thursday, December 21, 2006