Teacher’s Name(s)
St. Mary’s Episcopal School Marlene Shaw Early Childhood Center
Student Information Form 2017-2018
Please complete this form within the Word document by Friday, August 11th. Click on the grey spaces to enter information. The boxes will expand to accommodate the length of your text. Please print the completed form, sign, and return to the ECC office.
Child’s Full Name: Birth Date:
Name to be used at school:
Address:
Father’s Name:
Father’s Occupation: Home Phone:
Father’s Employer: Work Phone:
Father’s Email: Cell Phone:
Mother’s Name:
Mother’s Occupation: Home Phone:
Mother’s Employer: Work Phone:
Mother’s Email: Cell Phone:
Siblings:
Name:
Age: Male Female
School Attending:
Name:
Age: Male Female
School Attending:
Name:
Age: Male Female
School Attending:
Language(s) spoken at home:
Paternal Grandparents’ Names:
Address: Phone:
Maternal Grandparents’ Names:
Address: Phone:
Names of other Care Providers: Language of Caregiver:
Please give us a brief medical background for your child. A detailed Health Center form for the school nurse is also required. You will receive additional information about this form from the Health Center.
Medical Problems: Regularly taken medication:
Premature Birth:
Fears:
Allergies: Regularly taken allergy medication:
Food Restrictions:
St. Mary’s strives to be a nut free facility. All cafeteria meals and classroom snacks are nut free.
Speech Therapy: Yes No Wears Glasses: Yes No
Language Therapy: Yes No
Child’s Previous School:
Transportation:
Parent Carpool Drivers’ names
Other children in carpool
Tricycle Helmets:
My daughter may ride a tricycle with a helmet without a helmet.
I understand that I have to provide a helmet if needed.
Permission to publish student information and artwork:
There are times during the school year that St. Mary’s art teachers submit student work to various off-campus exhibits or contests. We are usually required to include the student’s name, address, and phone number on the application form. Students and their parents are notified when any work is submitted to an off-campus exhibit or contest.
I give permission for my daughter’s name, address, phone number and artwork to be submitted to an off-campus contest or exhibition.
I do not give permission for my daughter’s name, address, phone number and artwork to be submitted to an off-campus contest or exhibition.
Parents as Experts: Please list any special talents, hobbies or skills you would be willing to share with our girls. Examples could be sewing, yoga, gardening, music, scrapbooking, languages, etc.
Parent Signature ______Date ______