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STUDENT NAME _____________________________________________________ D.O.B.: ___________
STUDENT RESIDENTAL ADDRESS
STREET_________________________________________ APT.__________
CITY___________________________,NY ZIP_____________
HOME PHONE ______________________________________
STUDENT MAILING ADDRESS (only if different than Residential)
STREET_____________________________________________ APT.________
CITY____________________________,NY ZIP_____________
HOME PHONE ________________________________________
GUARDIAN 1
NAME ________________________________________________________________________________________
(Mr., Mrs., Ms., Miss) (First) (Middle) (Last) (Jr / Sr / III / IV)
STREET ____________________________________________________________________________________APT.#___________________
CITY _____________________________________________ STATE _________________________ ZIP _____________________________
HOME PH _______________________________ WORK PH ___________________________ Cell PH ________________________________
EMAIL ADDRESS_____________________________________________________________________________________________________
PLACE OF EMPLOYMENT _________________________________________________________________________________________________________
Relationship to student (mother/father/etc.) _______________________
Living with student? Yes ________ No ________
GUARDIAN 2
NAME ________________________________________________________________________________________
(Mr., Mrs., Ms., Miss) (First) (Middle) (Last) (Jr / Sr / III / IV )
STREET _____________________________________________________________________________________APT.#__________________
CITY _____________________________________________ STATE ___________________________ ZIP __________________________
HOME PH _______________________________ WORK PH _____________________________ Cell PH ________________________________
EMAIL ADDRESS_____________________________________________________________________________________________________
PLACE OF EMPLOYMENT _________________________________________________________________________________________________________
Relationship to student (mother/father/etc.) _______________________
Living with student? Yes ________ No ________
Paperless option: Do you wish to receive notifications via your computer? Check if Yes_______
Preferred email address ____________________________________________________
Person(s) to be contacted in case of emergency if parent/guardian cannot be reached. Please list in the order you would like them called.
NAME __________________________________________________________________ RELATIONSHIP ____________________________ PHONE________________________
NAME __________________________________________________________________ RELATIONSHIP ____________________________ PHONE________________________
NAME ________________________________________________ _________________ RELATIONSHIP _____________________________ PHONE________________________
OTHER CHILDREN IN FAMILY who are in the school district:
GRADE_______________ NAME _______________________________________
GRADE_______________ NAME _______________________________________ GRADE_______________ NAME _______________________________________
GRADE_______________ NAME _______________________________________
EMERGENCY INFORMATION If available, provide updated immunization records for your child with this form.
PHYSICIAN ______________________________________________ PHONE _______________________
HOSPITAL CHOICE __________________________________
DENTIST ________________________________________________ PHONE _______________________
Allergies: Food ______________________ Insect ______________ Medication ______________________________
Medical Condition ________________________
EMERGENCY DISMISSAL INFORMATION
In the event of an EARLY DISMISSAL due to inclement weather or other emergency, please indicate if your child will be picked up or bussed. Choose ONE and complete the information. NOTICE: the school WILL NOT contact parents individually in the event of an unexpected school closing.
_____ Please transport my child to our home on his/her regular bus.
_____ My child will be picked up by a guardian or emergency contact. I will listen to the radio for early dismissal information, or call the school closing line at 256-4099 if a winter storm is predicted. I understand that if I am not there by dismissal, my child will be put on the bus.
_____ Bus my child to the following address in the New Paltz Central School District:
Name________________________________________Tel.#____________________________Relationship_____________________________________
Address_______________________________________________________________________________________________Bus #__________________
The people listed on this form (contacts and guardians) are authorized to pick up my child from school or from the bus stop. In case of a medical emergency, we hereby authorize the school district to seek emergency medical assistance for our child if we cannot be reached.
Signature of Parent/Guardian ________________________________________________Date __________
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