STUDENT MAILING ADDRESS   (only if different than Residential)

STREET_____________________________________________ APT.________

CITY____________________________,NY ZIP_____________

HOME PHONE ________________________________________

GUARDIAN 1                        

 NAME ________________________________________________________________________________________

                   (Mr., Mrs., Ms., Miss)                           (First)                                 (Middle)                                                 (Last)                                                                                (Jr / Sr / III / IV)

STREET ____________________________________________________________________________________APT.#___________________

CITY _____________________________________________   STATE _________________________   ZIP _____________________________

HOME PH _______________________________ WORK PH ___________________________ Cell PH ________________________________

EMAIL ADDRESS_____________________________________________________________________________________________________

PLACE OF EMPLOYMENT _________________________________________________________________________________________________________

Relationship to student (mother/father/etc.) _______________________

Living with student? Yes ________   No ________

GUARDIAN 2 

NAME ________________________________________________________________________________________

                   (Mr., Mrs., Ms., Miss)                           (First)                                 (Middle)                                               (Last)                                                                             (Jr / Sr / III / IV )

STREET _____________________________________________________________________________________APT.#__________________

CITY _____________________________________________   STATE ___________________________   ZIP __________________________

HOME PH _______________________________ WORK PH _____________________________ Cell PH ________________________________

EMAIL ADDRESS_____________________________________________________________________________________________________

PLACE OF EMPLOYMENT _________________________________________________________________________________________________________

Relationship to student (mother/father/etc.) _______________________

Living with student? Yes ________   No ________

Paperless option: Do you wish to receive notifications via your computer? Check if Yes_______

Preferred email address ____________________________________________________

Person(s) to be contacted in case of emergency if parent/guardian cannot be reached. Please list in the order you would like them called.

NAME __________________________________________________________________ RELATIONSHIP ____________________________   PHONE________________________

NAME __________________________________________________________________ RELATIONSHIP ____________________________   PHONE________________________  

NAME ________________________________________________ _________________ RELATIONSHIP _____________________________   PHONE________________________          

OTHER CHILDREN IN FAMILY who are in the school district:

GRADE_______________       NAME _______________________________________ 

GRADE_______________       NAME _______________________________________                                                                                                                                                                                                                                    GRADE_______________       NAME _______________________________________                                                                                                                                        

GRADE_______________       NAME _______________________________________

EMERGENCY INFORMATION  If available, provide updated immunization records for your child with this form.

PHYSICIAN ______________________________________________ PHONE _______________________

HOSPITAL CHOICE __________________________________

DENTIST ________________________________________________ PHONE _______________________      

Allergies: Food ______________________   Insect ______________       Medication ______________________________

Medical Condition ________________________                                                                                

     EMERGENCY DISMISSAL INFORMATION                                                                                                                      

    In the event of an EARLY DISMISSAL due to inclement weather or other emergency, please indicate if your child will be picked up or bussed. Choose ONE and complete the information. NOTICE: the school WILL NOT contact parents individually in the event of an unexpected school closing.

_____ Please transport my child to our home on his/her regular bus.

_____ My child will be picked up by a guardian or emergency contact. I will listen to the radio for early dismissal information, or call the school closing line at 256-4099 if a winter storm is predicted. I understand that if I am not there by dismissal, my child will be put on the bus.

_____ Bus my child to the following address in the New Paltz Central School District:

Name________________________________________Tel.#____________________________Relationship_____________________________________

Address_______________________________________________________________________________________________Bus #__________________

The people listed on this form (contacts and guardians) are authorized to pick up my child from school or from the bus stop. In case of a medical emergency, we hereby authorize the school district to seek emergency medical assistance for our child if we cannot be reached.

Signature of Parent/Guardian ________________________________________________Date __________