The SCORE Center
Student Information
Student name:___________________________DOB:______________Grade:_____
Home school:________________________Gender:___________Race:___________
Reason for assignment:___________________________________________________
Transportation Arrangements: ____________________________________________
EC Category(if applicable): NA/ LD/ BED/ EMD/ Other________________________
(If student is EC include a copy of current IEP and Behavior Plan)
List medications taken at school:______________________________________
Other health concerns:______________________________________________
PARENT INFORMATION
Parent/Legal Guardian:_____________________________________________
Student resides with:________________________________________________
Home address:_____________________________________________________
Street/Apt.# City Zip Code
Home Phone #:_____________________________________________________
Work Phone #:________________________ ____________________________
Parent/Guardian name & number Parent/Guardian name & number
Emergency Contact_______________________________________________________
Name Phone # Relationship
__________________________________________________________
Name Phone # Relationship
Authorized adult(s) who may pick up student:
________________________________________________________________________
Name Phone # Relationship
Classes/Courses:
