____________________________________________________________________________________

STUDENT'S LAST NAME                                      FIRST NAME
 

LAST NAME (S) OF THE ADULT (S) WITH WHOM THE STUDENT RESIDES:
 

1. MR.____________________________   2. MRS. / MS.____________________________
 

HOME PHONE:____________________________________________________________
 
 

WHERE CAN YOU BE REACHED DURING DAYTIME HOURS?

1. DAY TIME PHONE ________________  2. DAY TIME PHONE ___________________

1. PAGER/CELL _____________________  2. PAGER/CELL ________________________

1. E-MAIL (PLEASE SEND ME ONE)          2. E-MAIL (PLEASE SEND ME ONE)
 

1.__________________________________  2.____________________________________

                    SIGNATURE                                                              SIGNATURE
 

P.S.  I HOPE THAT YOU HAVE TAKEN THE TIME TO DISCUSS THE FIRST PAGE WITH YOUR STUDENT. PLEASE HAVE YOUR STUDENT RETURN THIS PAGE TOMORROW.