STUDENT DATA FORM

(Where choices are given, circle one.)

STUDENT NAME_________________________________________________________________

SEX:        (M)ale        (F)emale

RACE:    (A)sian    (B)lack    (H)ispanic    (I)ndian    (P)acific Ilander    (W)hite

GRADE__________________

BIRTHDATE________/_______/_______

CUSTODY:    (1) Both    (2) Mother    (3) Father    (4) Other

PLEASE PRINT

PARENT OR GUARDIAN'S

NAME______________________________________________________

ADDRESS___________________________________________________________________

CITY____________________________________STATE________ZIP____________-_________

PHONE_________________________________CELL PHONE______________________

STUDENT'S SOCIAL SECURITY NUMBER___________________-________-__________

SCHOOL LAST ATTENDED___________________________________________________