ALBERT GALLATIN AREA SCHOOL DISTRICT
STUDENT INFORMATION/EMERGENCY CARD
Student’s Last Name: ______First Name: ______M.N.: ______
Mailing Address: ______Additional Address: ______
City: ______State: PA Zip: ______Home Phone: ______-______
Birth Date: ______Sex: M___ or F___ Grade: ______HR Teacher: ______
Resides with: ___ Parents ___ Mother Only ___Father Only ___Guardian ___Foster Parent
Bus # AM _____ Bus # PM ______Location of Bus Stop: ______
Custody papers on file at school: ______Yes ______No Social Security #: ______
Race: ____ American Indian/Alaskan Native ____ Black/African American (Non-Hispanic) ____ Hispanic
____ Multi-Racial _____ White _____ Asian ______Native Hawaiian or other Pacific Islander
Last School Attended: ______(if different)
Has student previously attended an AG School? ____ If yes, list school ______
Parent/Guardian Contact Information:
Mother’s Name: ______Father’s Name:______or Guardian’s Name: ______Family Email Address: ______
Mailing Address: ______
City: ______, State: PA Zip: ______
Home Phone: ______Mother’s Cell: ______Father’s Cell: ______
Mother’s Work Phone: ______Father’s Work Phone: ______
Parent and/or Guardian is currently a fulltime active duty member of the Armed Forces? _____Yes _____ No
Additional Mailing Address, if needed for Shared Custody:
Parent/Guardian Name: ______Relationship:______
Address: ______City: ______State: ____ Zip: ______
Emergency Contact Information: (List (3) relatives/friends the school can contact if you are unavailable.)
Name: ______Relationship: ______
Home Phone: ______Cell Phone: ______Work Phone: ______
Name: ______Relationship: ______
Home Phone: ______Cell Phone: ______Work Phone: ______
Name: ______Relationship: ______
Home Phone: ______Cell Phone: ______Work Phone: ______
(PLEASE TURN OVER AND COMPLETE REVERSE SIDE)
I have read and agree to the following: Detailed district policies and procedures are listed in handbook and district website.
1. Student/Family has received/read Student Handbook. YES _____ NO ____
2. Permission granted for pictures or media productions for classroom
and other school-wide events. YES _____ NO ____
3. Permission granted for classroom Internet Activities YES _____ NO____
4. Permission to participate in Physical Education Classes. YES _____ NO ____
If NO, list reason. ______
PLEASE LIST FIRST AND LAST NAMES OF BROTHERS AND/OR SISTERS WHO ATTEND THIS SCHOOL:
______
______
Did your child attend a preschool program? ______Yes ______No
At what age did he/she start preschool: ______
If Yes, list preschool Name and Address they attended: ______
______
Did your child participate in the Imagination Library program: ______Yes ______No
Parent/Guardian Signature ______ Date ______