GRADE:

ARG/STUDENT LOCATOR

LANGUAGE SPOKEN AT HOME:

ETHNICITY:

1 Amer. Indian 2 Asian 3 African Amer. 4 Hispanic 5 White

HOME CAMPUS:

001, Haltom High 002, Richland High 012, Shannon High School 010, Birdville High School 041, Haltom Middle 042, North Richland Middle 043, Richland Middle 044, North Oaks Middle 045, Watauga Middle 046, Smithfield Middle 047, North Ridge Middle 101, Birdville Elem. 102, David E. Smith Elem. 103, W.T. Francisco Elem. 104, Jack C. Binion Elem. 105, Alliene Mullendore Elem. 106, Richland Elem. 107, Smithfield Elem. 108, Snow Heights Elem. 109, South Birdville Elem. 110, O.H. Stowe Elem. 111, West Birdville Elem. 112, Holiday Heights Elem. 113, Watauga Elem. 114, Grace E. Hardeman Elem. 115, W.A. Porter Elem. 116, Carrie F. Thomas Elem. 117, Foster Village Elem. 118, North Ridge Elem. 119, John D. Spicer Elem. 120, Green Valley Elem. 121, Walker Creek Elem.

STUDENT LEGAL NAME:
	LAST	FIRST	MIDDLE	GENERATION(Jr.,Sr.,II,III,etc.)

GENDER:

Male Female

BIRTHDATE(mm/dd/yyyy):

HOME ADDRESS:						PHONE:
	HOUSE #	STREET NAME	APT.	CITY	ZIP CODE		INDICATE WITH “U” IF UNLISTED

PARENT/GUARDIAN #1:				EMPLOYER:
	LAST	FIRST	RELATIONSHIP

E-MAIL:

WORK#:

CELL#:

PARENT/GUARDIAN #2:				EMPLOYER:
	LAST	FIRST	RELATIONSHIP

E-MAIL:

WORK#:

CELL#:

ANY MEDICAL PROBLEMS?

Yes No

IF "YES", EXPLAIN:

EMERGENCY CONTACT #1 (OTHER THAN PARENTS/DR.)	RELATIONSHIP	PHONE:
EMERGENCY CONTACT #2 (OTHER THAN PARENTS/DR.)	RELATIONSHIP	PHONE:
EMERGENCY CONTACT #3 (OTHER THAN PARENTS/DR.)	RELATIONSHIP	PHONE:

FAMILY PHYSICIAN:

PHONE:

HOSPITAL:

I authorize the named physician or in the absence of other person/parents/physician the school officials to render such treatment as may be deemed necessary in an
emergency, for the health of my child.		(Must be completed and initialed for this authorization.)
	INITIALS

I accept financial responsibility for emergency care and/or transportation of my child.
	INITIALS
I acknowledge receipt of a copy of the Code of Conduct, Student Handbook (all grades), and DAEP Guidelines.
	INITIALS

SIGNATURE:	DATE(mm/dd/yyyy):
COMMENTS: