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2021-2022 Form: Pupil Data Sheet

Please complete the form below. Required fields marked with an asterisk *

Student Name

First Name*

Answer Required

Last Name*

Answer Required

Date of Birth*

Answer Required

Social Security Number*

Answer Required

Home Address*

Answer Required

Home Phone*

Answer Required

Insurance Carrier*

Answer Required

Insurance Policy #*

Answer Required

Who resides at home with student?*

Answer Required

Name of Your Child's Physician*

Answer Required

Phone Number of Your Child's Physician*

Answer Required

Contact Info of Parent/Guardian #1

First Name*

Answer Required

Last Name*

Answer Required

Relationship to Student*

Answer Required

Email Address*

Answer Required

Cell Phone #*

Answer Required

School District You Reside In*

Answer Required

Contact Info of Parent/Guardian #2

First Name*

Answer Required

Last Name*

Answer Required

Relationship to Student*

Answer Required

Email Address*

Answer Required

Cell Phone #*

Answer Required

School District You Reside In*

Answer Required

Emergency Contact Information

Name*

Answer Required

Relationship to Student*

Answer Required

Phone Number*

Answer Required

Name*

Answer Required

Relationship to Student*

Answer Required

Phone Number*

Answer Required

The following person(s) is NOT authorized to pick up my child:

Name

Answer Required

Name

Answer Required

Name

Answer Required

School Emergency Procedures

New Horizon School has adopted the following procedures in caring for your child when he/she becomes sick or injured at school:

IN CASE OF EMERGENCY AND/OR NEED MEDICAL OR HOSPITAL CARE:

Unless directed otherwise, the school will first call home. If there is no answer:

The school will call the cell phone of the father, mother, guardian, and/or their place of employment.
If there is no answer from any of the above options, the school will then call all other telephone numbers listed.
If we are unsuccessful with all of the above options, then we will call for an ambulance, if necessary, to transport the child to a local medical facility.

*The school will continue to call the parents or guardians until one is reached.

By typing your name below, you are agreeing to an electronic signature of this document.*

Answer Required