Student Profile

Student Name: ________________________________________________________

Address: _________________________________________________________________________

Home Phone: ________________________ Male / Female (circle)

Birthdate: __________________________ SS# _____________________________

Father’s Name: ________________________________________________________

Address: __________________________________________________________________________

Cell Phone: ______________________ E-mail:__________________________________

Work place and phone:______________________________________________________________

Mother’s Name: ________________________________________________________

Address: __________________________________________________________________________

Cell Phone: _______________________ E-mail:__________________________________

Work place and phone: ______________________________________________________________

List other children in family presently enrolled at Fort Dale Academy:

Name Grade

________________________________________________________

________________________________________________________

List other children in family enrolled in other schools or pre-schools:

Name School / Grade

_______________________________________________________

_______________________________________________________

Emergency Contact: (Please provide phone number and relationship to student.)

_____________________________________________________________________________________

Doctor’s Name / Phone: _____________________________________________

Food / drug allergies: _______________________________________________