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Cleary School 2021- 2022 Student Information Form
Student Name
*
DOB:
*
+
Street Address
*
Address Line 2
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
#1. Parent/Guardian Contact Information
Name
*
Relationship
*
Home Phone Number
Mobile Phone Number
*
Email
*
Do you reside at the same address as your child
*
YES
NO
If NO, Please enter your current address
#2. Parent/Guardian Contact Information
Name
Relationship
Home Phone Number
Mobile Phone Number
Email
Resides at the same address as child/student?
*
YES
NO
If NO, Please enter your current address
Student Emergency Contacts (Please list two)
Primary Emergency Contact
Relationship
Primary contact phone number
Secondary Emergency Contact
Relationship
Contact phone number
Student Medical Information
Pediatrician Name
*
Phone Number
*
Street Address
*
Address Line 2
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Does your child have any allergies
*
Yes
No
If Yes, Please List Allergies below:
*
Does your child take any prescription medications?
*
Yes
No
If Yes, Please list medications, dosage and frequency below
*
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