Student Information Form printable pdf download

Student Information Form

4/16

Today’s date

Student’s name as shown on birth certificate or I-94:

First name

Middle

Last Name

Name student prefers to be called

School the student most recently attended

Student’s date of birth

_______________________ Grade in school for 2016-17

Student’s home address with zip code

How did you learn about Utah International Charter School?

Parent/Guardian first and last name

Parent/Guardian phone numbers: Home

Cell

Work

Relationship to student (mother, father, other)

Parent/Guardian email address if available

Parent/Guardian first and last name

Parent/Guardian phone numbers: Home

Cell

Work

Relationship to student (mother, father, other)

Parent/Guardian address if different from student

Parent/Guardian email address if available

In case of emergency, if we cannot reach you, please list two adult family members or friends we can contact,

and that you authorize to check your student out of school if necessary.

Name

Phone number

Name

Phone number

Student’s regular doctor or health care provider

Name

Phone number

Student Information Form