Student Information Record

STUDENT:

Name:_______________________________________ Date of Birth___________________

School ______________________________________________________ Grade_________

LEGAL GUARDIANS:

Name______________________________        Name_______________________________

Address____________________________        Address______________________________

Hm phone__________________________        Hm phone____________________________

Cell phone__________________________       Cell phone____________________________

E-mail______________________________       E-mail_______________________________

Occupation__________________________       Occupation___________________________

Wk phone___________________________      Wk phone____________________________

EMERGENCY INFORMATION:

List two people (other than parents) who can be contacted in case of emergency:

Name______________________________           Name_______________________________

Phone______________________________          Phone_______________________________

Relationship_________________________         Relationship__________________________

Child’s Doctor__________________________      Phone_______________________________

Child’s Dentist__________________________     Phone_______________________________

Please list and explain any medical, physical, behavioral, or psychological conditions:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Please list any medications that your child is currently taking:

_______________________________________________________________________

ACADEMIC INFORMATION

Please list academic areas in which your child has difficulty:

_______________________________________________________________________

Please list any diagnosed learning needs:

_______________________________________________________________________

Please list any special services, accommodations and/or modifications your child receives at school:

________________________________________________________________________

________________________________________________________________________

How does your child work best at home?

________________________________________________________________________

________________________________________________________________________

Please list any other information that you believe will be helpful for me to know when working with your child:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

Parent/Guardian Signature_________________________________________________

Date_____________________________________________________________________

How did you hear about Catron Community Learning Center?

___School

___The New Mexican

___Kids Summer

___New Mexico Kids

___Tumbleweeds

___Yellow Pages

___Friend or Relative

___Internet Search

___Church

___Other ______________________________