Tuscaloosa County School System


    SCHOOL: ________________________________________________ GRADE: __________ DATE: ________________________


    STUDENT’S NAME: _________________________________________________________________________________________

                                                    (First)                                                       (Middle)                                                   (Last)


    DATE OF BIRTH: ____________________ SEX: ______ RACE: ______ SOCIAL SECURITY NUMBER: ____________________


    *ADDRESS: ________________________________________________________________________________________________

                                    (Street/Road)                                                           (City)                                        (State)                      (Zip)


    HOME PHONE: __________________________                  How long have you lived at the address above? ____________________


    STUDENT LIVES WITH: ____BOTH PARENTS    ____MOTHER    ____FATHER    ____LEGAL GUARDIAN    OTHER: ___________________


    MOTHER’S/GUARDIAN’S NAME: ______________________________________________________________________________


    FATHER’S/GUARDIAN’S NAME: _______________________________________________________________________________


    MOTHER’S/GUARDIAN’S PLACE OF WORK: ________________________________________ PHONE: ____________________


    FATHER’S/GUARDIAN’S PLACE OF WORK: _________________________________________ PHONE: ____________________


    LAST SCHOOL ATTENDED: _____ ______________________________________________________ GRADE: __________


    ADDRESS OF LAST SCHOOL: ________________________________________________________________________________

                        (Street/Road)                                                                       (City)                        (State)            (Zip)


    Is the student eligible for Special Education services? ____Yes ____No (If Yes, describe _________________________________.)

    Is the student eligible for Chapter I/Title I services? ____Yes ____No

    Was the student eligible for a 504 plan at his/her previous school? ____Yes ____No

    Is the student currently suspended from the previous school? ____Yes ____No

    Has the student been expelled from the previous school? ____Yes ____No

    Has the student attended an alternative school? ____Yes ____No

    Is the student taking medication(s) that will be administered during school hours? ____Yes ____No

                    (If Yes, list medications below and complete appropriate school medication forms.)

                    Medication(s): ______________________________________________________________________________________

                    Physician prescribing medication(s): _____________________________________________________________________

    Does the student have other medical/health needs of which the school needs to be aware? ____Yes ____No

                    (If Yes, describe briefly in the space below and complete a MEDICAL ALERT card.)

                    Medical/Health conditions: __________________________________________________________________________________________________________________________________________________________________________


    Family Doctor: _______________________________________________________________ Phone: ____________________

    Medical Insurance: __________________________________________________________________________________________


    Student Transportation To School:         ______Car    ______Walk    ______Commercial Van    ______School Bus Number________

    Student Transportation From School:     ______Car    ______Walk    ______Commercial Van    ______School Bus Number________


    Will the student be enrolled in the school’s Extended Day Program?      ______No        ______Occasionally        ______Daily




    List persons to be contacted in the event of an accident, illness, injury or other emergency if parents/guardians cannot be reached:


    Name: _____________________________________________________________________ Phone: ____________________


    Name: _____________________________________________________________________ Phone: ____________________


    List persons other than parents/guardians with permission to check student out of school or pick up student from school:


    Name: _____________________________________________________________________ Phone: ____________________


    Name: _____________________________________________________________________ Phone: ____________________


    *The signature of the parent/guardian below indicates that the address above is the legal address of residence for the student and that the above information is accurate and current. It is the responsibility of the parent/guardian to provide school officials with verifiable student information. It is the responsibility of the parent/guardian to notify the school immediately in writing of any change in student information.


    “I, the undersigned, do hereby authorize school officials to contact directly the persons named above in the event of an emergency involving this student, and do authorize the named physician(s) to render such treatment as may be deemed necessary in an emergency, for the health of said child. In the event physicians, other persons named above, or parents cannot be contacted, school officials are hereby authorized to seek emergency assistance necessary for the health of the aforesaid child. I will not hold school officials financially responsible for the emergency care and/or transportation for said child.”



    _____________________________________________________________________________ Date: ___________________

    Signature of Parent/Guardian

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