US History Student Information
Student’s Name (please print clearly):
Class:
Student resides with:
Mother’s Name:
Home Phone #:
Cell Phone #:
Email:
Father’s Name:
Home Phone #:
Cell Phone #:
Email:
Guardian’s Contact Information:
Home Phone #:
Cell Phone #:
Email:
If English is not spoken at home, please provide a contact person to translate important information:
Name:
Home Phone #:
Cell Phone #:
Email:
Does the student have: (please check all that apply)
access to a computer nightly
access to the internet nightly
access to a printer nightly
Please share any additional information that you feel would be helpful for me to know
By signing this form, I have reviewed and agree to the policies and procedures of the class.
Parent / Guardian Signature:
Student Signature:
Date:
Date: