De La Salle Middle School

Fields marked with an asterisk (*) are required.

Student Information
*Child's Legal Last Name:
*Child's First Name:
*Preferred Name:
*Child's Social Security #:
*Date of Birth:
*Sex:
*Grade Level (2011-2012 School Year):
Family Information
*Primary Adult Parent/Guardian:
Parent/Guardian Email:
*Adult Social Security #:
*Parental Status:
*Number in Household:
*Number of Children under 18:
*Address:
*City:
*State:
*Zip Code:
Home Phone:
Cell Phone:
Work Phone:
*Alternate Contact Name:
Alternate Contact Phone:
School Information
*Current School Name:
Address:
City:
State:
Zip Code:
Phone:
Fax:
*Years Attended:
*My child has, in the past, qualified for free or reduced lunch:
*How did you hear about our school?
Release of Information:	I hereby agree to allow all pertinent educational and medical records to be released to De La Salle Middle School at St. Matthew's from the current educational facility/district in which the child has been in attendance. Specific information requested includes standardized test results, attendance records, health records, discipline records, diagnostic testing, medical needs, documentation of diagnosis with educational recommendations special education(original evaluations, all re-evaluations, current EIP, leaning profiles, and/or504 plan).
*Parent/Guardian's E-signature
*Date:

Student Information