MEMPHIS STEM ACADEMY SCHOOL
STUDENT INFORMATION
2018 - 2019
   
            Sex:
                         (last name)                                                                           (first name)                                                      (middle name)  
     
Home Phone No. Soc. Sec. # Birthdate:
     
Birth City      Country      State      Nation      Race
     
Is English primary language spoken by student?   


 
     
If No, home language                           Is English language limited?

   
     
Home Address               


                   (street number)          (street name& destination)                     (apt no)                   (zip code)
     
Projected School 2018-2019            Grade   Date Attended
                                               (Assigned school per your address)  
     
Address of School                         
                 (street number)             (street name)                                     (city)                                    (state)          (zip code)  
     
Have you ever attended a Memphis City School?   
         
     
School Name      Grade   Date Attended  
     
Are you here on a school transfer?     
If, yes Name of your assigned school
     
Is student currently enrolled or has student ever been enrolled in a Special Education or Resource Program

   
                                                                                                                                    Does your child have a 504 Plan? 

   
     

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?


     
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?   

   
     
If no, list instructions
     
Student lives with:                              Both Natural Parents



          Father 



Mother 



   
                                                        Stepmother



    Stepfather



Guardian 



   
     
Is parent/guardian on active duty?



  If yes, which branch of service
     
Is parent/guardian employed on federal property?



If yes, where
     
Father’s name      Employer Work Phone CellPhone
     
Mother’s name    Employer Work Phone CellPhone
     
Guardian’s name Employer Work Phone CellPhone

(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 check the appropriate box 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  
     
2.     Name     Relationship Contact Number  
     
3.     Name     Relationship Contact Number  
     
By pressing Submit you verify that the information provided on this form is accurate and complete.          
     

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.