FRANKLIN COUNTY SCHOOL DISTRICT

STUDENT PERSONAL DATA FORM

Homeroom Teacher: ________________________ Grade: ____________ Bus Name/#: ____________________

What school will your child be attending? _______________________________________________________________

Student Name: ____________________________________________________________________________________

Last First Middle Name Called

Gender: ________ Race: ________ Birthdate: ______________ Social Security #: ______________________

City of Birth: _________________ Country of Origin: ________________ Primary Language: _________________

Physical Address: _________________________________________________________________________________

Street Name and Number

Mailing Address: __________________________________________________________________________________

Check if same as physical address

__________________________________________________________________________________

City State Zip County of Residence

Email Addresses: __________________________________________________________________________________

Does your child attend a Preschool Program? ___________ If yes, what preschool program? ___________________

Father’s Name: ____________________________ Mother’s Name: _______________________________________

Father’s Employer: _________________________ Mother’s Employer: ____________________________________

Home Phone: _____________________________ Home Phone: ________________________________________

Daytime Phone: ___________________________ Daytime Phone: ______________________________________

Cell Phone: _______________________________ Daytime Phone: ______________________________________

Child lives with: ___________________________________________________________________________________

If there is a special condition with regard to custody, please answer the following:

Who has physical custody? __________________ Who has legal custody? _________________________________

Relationship? _____________________________ Relationship? _________________________________________

List any brothers and sisters _________________________________________________________________________

And the schools they attend: _________________________________________________________________________

#1 Emergency Contact: _____________________________________________________________________________

Name Relationship Telephone Number

#2 Emergency Contact: _____________________________________________________________________________

Name Relationship Telephone Number

List all individuals and telephone numbers of those who are permitted to pick this student up from school:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

___________________________________ ______________________________________ ________________

Signature of Person Completing Form Relationship Date