Pupil information
Child's name: Social security number:
Custodian:
Custodian 1:
Social security number:
E-mail:
Phone number:
Adress:
Postal number & city:
Custodian 2:
Social security number:
E-mail:
Phone number:
Adress:
Postal number & city:
I am the only custodian
Name: Phone number:
Person to contact if custodian cannot be reached:
Date:
Other information:
Impaired vision
Impaired hearing Allergies
Vaccinated according to BVCs program
Custodian 1 allows for the following people to receive information about the child:
Custodian 2 allows for the following people to receive information about the child:
Custodian 2 gives consent Custodian 1 gives consent
Other first language Disability that staff needs to know about:
What kind:
Other:
Yes No Yes No
Signature custodian 2 Signature custodian 1
