Title (Mr. Mrs. Ms. Dr.)
Name - Last: First:
Middle:
Address: City:
State: Zip Code:
Home Phone:
Work Phone:
Cell Phone: Ext.
Email:
Occupation:
Employer:

Student Name: First, Middle & Last (Please Print)	Gender/DOB	Social Security Number	Grade Entering 2008-09 (ECC-12)	Public School According to Residence
1)
2)
3)
4)
5)

Religion:
Please list the Catholic parish sponsoring this family (if applicable):
Ethnicity (Please choose one): Caucasian African American Hispanic Asian Native American
Other (Please Specify):

Divorced and/or separated parents MUST have a copy of the divorce decree verifying custody arrangements on file with the school office.

Who is the custodial parent?

May child(ren) be released to non-custodial parent?

I give the school staff permission to release my child(ren) to the adults listed on this form or any adult SMSS would deem responsible to care for my child(ren).

I give the school staff permission to release my child(ren) ONLY to the adults listed on this form.

List three (3) adults and their daytime phone numbers, to whom the school is authorized to release your child(ren):

Adult Name(s)	Phone Number(s)	Relationship to Student
1.)
2.)
3.)

Emergency Medical Information:

Please list any pertinent medication/treatments/allergies, etc. for your child(ren) on the lines below:

Name   (List All Students in Family)
Medical Information   (Please write none, none known or N/A next to your child's name if there is nothing to report).