Student 1 Name

Student 1 Birthdate

Student 2 Name

Student 2 Birthdate

Student 3 Name

Student 3 Birthdate

Student 4 Name

Student 4 Birthdate

FAMILY INFORMATION

Mother: (Please complete all that apply)

First Name Last Name

Home Address

Home Telephone Mobile (Cell) Telephone

Home E-mail Address***

Occupation/Job Title

Employer

Business Address

Business Telephone Extension

Business E-mail Address

Father: (Please complete all that apply)

First Name Last Name

Home Address

Home Telephone Mobile (Cell) Telephone

Home E-mail Address***

Occupation/Job Title

Employer

Business Address

Business Telephone Extension

Business E-mail Address

In the case of separation or divorce, who should be listed in the school directory?

Both Parents Mother Father

To whom should correspondences be sent?

Both Parents Mother Father

To whom should e-mails be sent?

Both Parents Mother Father

Emergency Names & Phone Numbers:

Please provide a contact person (or two) if you cannot be reached:

Name Relationship to child

Telephone Mobile (Cell) Telephone

Name Relationship to child

Telephone Mobile (Cell) Telephone

Please indicate two (2) Meadowbrook families who would be a contact if you cannot be reached:

Name

Name

*** If there is more than one e-mail address at the same place of residence, please indicate the preferred e-mail address. In the near future this will be used for monthly mailings & notices of upcoming events.