When filling in address line please make sure you include correct street number & name, PO box if applicable, town, & zip code

STUDENT’S NAME: _____________________________________________

NEW ADDRESS: ________________________________________________________

TELEPHONE #: ___________________________

PARENT EMAIL ADDRESS______________________________________

DATE MOVED: ____________________________

WITH WHOM DOES THE STUDENT LIVE: _______________________________

DOES THIS INVOLVE A CHANGE OF TOWNS?   Yes   No

If Yes, From Which Town: _____________________________

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PLEASE COMPLETE THIS SECTION ONLY IF THERE IS A CHANGE

FROM PREVIOUSLY REPORTED INFORMATION:

NON-CUSTODIAL PARENT/GUARDIAN INFORMATION:

IS THERE IS A SECOND PARENT/GUARDIAN WHO DOES NOT LIVE WITH THE STUDENT, BUT WHO SHOULD ALSO RECEIVE/HAVE ACCESS TO STUDENT’S RECORDS:

NAME: ________________________________________________________________

RELATIONSHIP: _______________________________________________________

ADDRESS: ____________________________________________________________

PHONE #, HOME: ___________________________  WORK: ___________________

EMERGENCY INFORMATION

If parents cannot be reached, contact:

_______________________________________________  Phone: _________________

_______________________________________________  Phone: _________________

Allergies or health problems: ______________________________________________

In case of accident or serious illness, I request the school to contact me or the people designated above.

Parent Signature: ________________________________________________________

Date: ____________________________________________