Your name: ______________________________________________________

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

Social Security Number: ___________________________________________

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

Parent or Guardian 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 who live in your home: _______________________________

_________________________________________________________________

Emergency Contact Name: __________________________________________

Relationship: _____________________________________________________

Area Code and Phone Number: ______________________________________

Doctor’s Name: ___________________________________________________

Area Code and Phone Number: ______________________________________

Allergies: ________________________________________________________

Medical Insurance Company: ________________________________________

Policy Number: ___________________________________________________

Your e-mail address: _______________________________________________

Interpreting Agency Outside School: __________________________________

http://www.dcsofsd.org/ or http://www.ASLNIS.com/

Agency Phone Number and Area Code: _______________________________

CRS Phone Number (TDD to Voice): __________________________________

CRS Phone Number (Voice to TDD): __________________________________

Bus/Trolley Routes from Home to School: ______________________________

_________________________________________________________________

http://www.sdcommute.com

Bus/Trolley Routes from School to Home: ______________________________

_________________________________________________________________

Specialized Transportation Referral & Information for the Disabled and Elderly (STRIDE)
http://www.stridesd.org/

MTS Phone Number: _______________________________________________