Student Information Form
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1
2Lakeland Christian Academy ~ Student Information Form
First Parent
Name:
Lives w/student: ___Yes ___No
Address:
City:
State:
Zip:
Home Phone # (
)
Cell Phone # (
)
Social Security #:
Company/Employer Name:
Address:
City:
State:
Zip
Work Phone #: (
)
Second Work Phone # (
)
Reference Source: How did you hear about our school?
Parent Roster: May we include you on our parent roster? (_____) Yes
(_____) No
Second Parent
Name:
Lives w/student: ___Yes ___No
Address (if difference from Parent 1)
City:
State:
Zip
Home Phone # (
)
Cell Phone # (
)
Social Security #:
Company/Employer Name:
Address:
City:
State:
Zip:
Work Phone #: (
)
Second Work Phone # (
)
Child
Name:
Sex: (M / F)
Date of Birth: ___/___/___
Address (if difference from parent’s address above)
City:
State:
Zip
Home Phone #:(____) ________________________ Social Security
#:___________________________
Fluently Speaks English: (_____) Yes
(_____) No
Fluently Speaks Other Language, specify:_______________________________
Admittance Date: __/__/__ Enrollment Date:__/__/__/ Group:____ Catagory:_____Class:___________
Medical Information
Physician:
Phone# (
)
Alternate Phone: (
)
Address:
City:
State:
Zip:
Dentist:
Phone# (
)
Alternate Phone: (
)
Address:
City:
State:
Zip:
Preferred Hospital
Insurance Provider:____________________ Policy #:_______________Phone #: (_____)___________
Medical Form on File: (
) Yes
(
) No
Effective Date:___/___/___/ Expires ___/___/___
(continued on page 2)
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Parent category: Business