Memphis Business Academy

MEMPHIS BUSINESS ACADEMY MIDDLE SCHOOL and HIGH SCHOOL STUDENT INFORMATION 2017-2018

Sex (Student last name) (first name) (middle name)

Home Phone No. Soc. Sec. # Birth date

Birth City Country State Nation Race

Is English primary language spoken by student? Yes ______No _____

If No, home language Is English language limited? Yes _____ No _____

Home Address Is address on federal property? Yes ____ No ____ (street number) (street name & destination) (apt no.) (zip code)

Projected School 2017-2018 Grade (Assigned school per your address)

Address of School (street number) (street name) (city) (state) (zip code)

Have you ever attended a Memphis City School? Yes ____ No ____ or Charter School? Yes ______No _____

School Name Grade ______Date Attended

Are you here on a school transfer? Yes ____ No ____ If, yes Name of your assigned school

Is student currently enrolled or has student ever been enrolled in a Special Education or Resource Program? Yes ___ No ___ Does your child have a 504 Plan? Yes ___ No ___ Has the student had or currently has the following:

1. __ No known health problem 5. __ Hearing difficulties 9. __ Tuberculosis contact date _____ 13. __ Hemophilia (bleeder)

2. __ Asthma 6. __ Speech difficulties 10. __ Seizures (Epilepsy) 14. __ Sickle Cell Anemia

3. __ Allergies 7. __ Heart Problems 11. __ Diabetes 15. __ Sinusitis

4. __ Eye problems 8. __ Surgery (type) ______12. __ Kidney problems 16. __ Medical Diet prescribed (other than glasses) date ______17. other ______

Instructions for assistance for above medical problem(s): ______

Prescribed Medicine Taken On A Regular Basis: ______Taken at school ___ Yes ___ No

Special Condition (Possible Life Threatening Condition) ______(Such as food allergies, bee stings, etc.)

1st Email Address: ______2nd Email Address ______IT IS THE RESPONSIBILITY OF THE PARENT/GUARDIAN TO PROVIDE THE SCHOOL WITH SPECIFIC EMERGENCY PROCEDURES.

Insurance/Health Plan ______Number ______

Doctor or Clinic ______Phone No. ______Hospital ______

Disability ______May student participate in all school activities? Yes ___ No ___

If no, list instructions ______

Student lives with: Both Natural Parents ___ Yes No ___ Father___ Yes No ___ Mother ___ Yes No ___

Stepmother ___ Yes No ___ Stepfather ___ Yes No ___ Guardian ___ Yes No ___

Is parent/guardian on active duty? ___ Yes ___ No If yes, which branch of service ______

Is parent/guardian employed on federal property? ___ Yes No ___ If yes, where ______

Father’s name ______Employer ______work phone ______Cell phone ______

Mother’s name ______Employer ______work phone ______Cell phone ______

Guardian’s name ______Employer ______work phone ______Cell phone ______(if other than parent)

Emergency Friend #1 ______Relationship ______Daytime Phone ______

Emergency Friend #2 ______Relationship ______Daytime Phone ______

Instructions for pickup:(daycare, etc) ______

Parents/guardians, we need to know how your child will be going home. Please put an X in the appropriate space below:

______Picked up by car ______Ride MATA Bus ______Walk home

Please list all people authorized to pick up your child.

1. Name ______Relationship ______Contact Number ______

Your signature verifies that the information provided on this form is accurate and complete.

______(PARENT OR GUARDIAN’S SIGNATURE) (DATE)

Memphis Business Academy does not discriminate in its programs or employment on the basis of race, color, religion, national origin, handicap/disability, sex or age.