Information Record

Catron Community Learning Center

Student Information Record

STUDENT:

 

Name______________________________________________________________

 

Date of Birth________________________________________________________ 

 

School ____________________________________________________________

 

Grade_____________

 

LEGAL GUARDIANS:

Legal Guardian #1
 

Name______________________________________________________________

 

Address______________________________________________ Zip___________
 

Hm phone_____________________________

 

Cell phone____________________________

 

E-mail_____________________________________________________________

 

Occupation_________________________________________________________

 

Wk phone__________________________________________________________

 

Legal Guardian #2

 

Name_______________________________ Address______________________________

Hm phone____________________________

Cell phone____________________________

E-mail_______________________________ Occupation___________________________

Wk phone____________________________

 

Name_______________________________ Phone_______________________________ 

 

EMERGENCY INFORMATION:

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

Name______________________________
Phone______________________________
Relationship_________________________

 

Name______________________________
Phone______________________________
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 ___________________________________________

 

 

 

Contact Us Today!

Catron Community Learning
306 Catron Street
Santa Fe, NM 87501


Phone: 505.983.8102

E-mail: director@catroncommunitylearning.com

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