<p> MEMPHIS BUSINESS ACADEMY MIDDLE SCHOOL and HIGH SCHOOL STUDENT INFORMATION 2017-2018</p><p>Sex (Student last name) (first name) (middle name)</p><p>Home Phone No. Soc. Sec. # Birth date </p><p>Birth City Country State Nation Race </p><p>Is English primary language spoken by student? Yes ______No _____</p><p>If No, home language Is English language limited? Yes _____ No _____</p><p>Home Address Is address on federal property? Yes ____ No ____ (street number) (street name & destination) (apt no.) (zip code)</p><p>Projected School 2017-2018 Grade (Assigned school per your address)</p><p>Address of School (street number) (street name) (city) (state) (zip code) </p><p>Have you ever attended a Memphis City School? Yes ____ No ____ or Charter School? Yes ______No _____</p><p>School Name Grade ______Date Attended </p><p>Are you here on a school transfer? Yes ____ No ____ If, yes Name of your assigned school </p><p>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:</p><p>1. __ No known health problem 5. __ Hearing difficulties 9. __ Tuberculosis contact date _____ 13. __ Hemophilia (bleeder)</p><p>2. __ Asthma 6. __ Speech difficulties 10. __ Seizures (Epilepsy) 14. __ Sickle Cell Anemia</p><p>3. __ Allergies 7. __ Heart Problems 11. __ Diabetes 15. __ Sinusitis</p><p>4. __ Eye problems 8. __ Surgery (type) ______12. __ Kidney problems 16. __ Medical Diet prescribed (other than glasses) date ______17. other ______</p><p>Instructions for assistance for above medical problem(s): ______</p><p>Prescribed Medicine Taken On A Regular Basis: ______Taken at school ___ Yes ___ No</p><p>Special Condition (Possible Life Threatening Condition) ______(Such as food allergies, bee stings, etc.)</p><p>1st Email Address: ______2nd Email Address ______IT IS THE RESPONSIBILITY OF THE PARENT/GUARDIAN TO PROVIDE THE SCHOOL WITH SPECIFIC EMERGENCY PROCEDURES.</p><p>Insurance/Health Plan ______Number ______</p><p>Doctor or Clinic ______Phone No. ______Hospital ______</p><p>Disability ______May student participate in all school activities? Yes ___ No ___</p><p>If no, list instructions ______</p><p>Student lives with: Both Natural Parents ___ Yes No ___ Father___ Yes No ___ Mother ___ Yes No ___</p><p>Stepmother ___ Yes No ___ Stepfather ___ Yes No ___ Guardian ___ Yes No ___</p><p>Is parent/guardian on active duty? ___ Yes ___ No If yes, which branch of service ______</p><p>Is parent/guardian employed on federal property? ___ Yes No ___ If yes, where ______</p><p>Father’s name ______Employer ______work phone ______Cell phone ______</p><p>Mother’s name ______Employer ______work phone ______Cell phone ______</p><p>Guardian’s name ______Employer ______work phone ______Cell phone ______(if other than parent)</p><p>Emergency Friend #1 ______Relationship ______Daytime Phone ______</p><p>Emergency Friend #2 ______Relationship ______Daytime Phone ______</p><p>Instructions for pickup:(daycare, etc) ______</p><p>Parents/guardians, we need to know how your child will be going home. Please put an X in the appropriate space below:</p><p>______Picked up by car ______Ride MATA Bus ______Walk home</p><p>Please list all people authorized to pick up your child.</p><p>1. Name ______Relationship ______Contact Number ______</p><p>2. Name ______Relationship ______Contact Number ______</p><p>3. Name ______Relationship ______Contact Number ______</p><p>Your signature verifies that the information provided on this form is accurate and complete.</p><p>______(PARENT OR GUARDIAN’S SIGNATURE) (DATE)</p><p>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.</p>