Your name:                                                                                                   

Birthdate (month/date/year){xx/xx/xxxx}:                                                         

Social Security Number:                                                                                 

Parent or Guardian’s Name:                                                                            
                              (Mom’s first and last name)

Parent or Guardian’s Name:                                                                            
                                                         (Dad’s first and last name)

Address:                                                                                                       

City, State and Zip:                                                                                        

Phone Number with Area Code:                                                                       

Parent or Guardian’s Work Area Code and Phone Number: (Mom)
                                                                                                                     

Parent or Guardian’s Work Area Code and Phone Number: (Dad)
                                                                                                                     

Cell Phone Number:                                                                                        

Who? :                                                                                                           

What language do your parent/s speak?                                                            

Brothers’ and Sisters’ Name/s:                                                                         

                                                                                                                     

Names of people that live in your home:                                                           

                                                                                                                     

Emergency Contact Name:                                                                              

Relationship:                                                                                                   

Area Code and Phone Number:                                                                        

Doctor’s Name:                                                                                               

Area Code and Phone Number:                                                                         

Allergies:                                                                                                        

Medication/s:                                                                                                  

Special Equipment (e.g. glasses, wheelchair, hearing aid)
                                                                                                                     

Your e-mail address: