STUDENT SYNERGY PROFILE General Information Legal First Name Legal Middle Name Legal Last Name State ID / Perm ID Gender Grade Male Female Birth Date Birth Place Birth Country Enrollment Date Primary Phone Number(s) Home Language Ethnicity /étnico: Asian Other: African American Caucasian (check if Hispanic / Latino) Native American /Alaskan Native, Tribe: Home Address Mailing Address Transportation My child live IN SCHOOL ZONE (Must provide eligible bus number address) My child lives OUT of SCHOOL ZONE (I will provide personal transportation daily) Bus Route (Morning) Morning Address Bus Route (Afternoon) Afternoon Address Parent/Guardian Custodial Information Relation: Name/nombre: Address Employer Father Check all Contact Allowed Education Has Custody Mailing Allowed Enrolling Parent Release To Financially Deceased that apply: Rights Responsible Cell Phone: Home Phone: Work Phone: ( ( ( Primary Not Listed Contact Phone) Primary Not Listed Contact Phone) Primary Not Listed Contact Phone) ( ) ( ) ( ) Name/nombre: Relation: Address Employer Mother Check all Contact Allowed Education Has Custody Mailing Allowed Enrolling Parent Release To Financially Deceased that apply: Rights Responsible Cell Phone: Home Phone: Work Phone: ( ( ( Primary Not Listed Contact Phone) Primary Not Listed Contact Phone) Primary Not Listed Contact Phone) ( ) ( ) ( ) In Case of Emergency: Names of persons who can assume temporary responsibility and are authorized to pick up. Name Relationship Home Phone Work Phone Other Phone Name Relationship Home Phone Work Phone Other Phone Name Relationship Home Phone Work Phone Other Phone Name Relationship Home Phone Work Phone Other Phone Name Relationship Home Phone Work Phone Other Phone Name Relationship Home Phone Work Phone Other Phone Name Relationship Home Phone Work Phone Other Phone Siblings: List all siblings attending school in the Espanola School District. Name Gender Grade School Name Gender Grade School
STUDENT SYNERGY PROFILE General Information Legal First Name Legal Middle Name Legal Last Name State ID / Perm ID Gender Male Female Grade Birth Date Birth Place Birth Country Enrollment Date Primary Phone Number(s) Home Language Ethnicity /étnico: Asian Other: African American Caucasian (check if Hispanic / Latino) Native American /Alaskan Native, Tribe: Home Address Mailing Address Transportation My child live IN SCHOOL ZONE (Must provide eligible bus number address) My child lives OUT of SCHOOL ZONE (I will provide personal transportation daily) Bus Route (Morning) Morning Address Bus Route (Afternoon) Afternoon Address Parent/Guardian Custodial Information Relation: Father Name/nombre: Address Employer Check all that apply: Contact Allowed Education Rights Has Custody Mailing Allowed Enrolling Parent Release To Financially Responsible Deceased Cell Phone: ( Primary Not Listed Contact Phone) ( ) Home Phone: ( Primary Not Listed Contact Phone) ( ) Work Phone: ( Primary Not Listed Contact Phone) ( ) Relation: Mother Name/nombre: Address Employer Check all that apply: Contact Allowed Education Rights Has Custody Mailing Allowed Enrolling Parent Release To Financially Responsible Deceased Cell Phone: ( Primary Not Listed Contact Phone) ( ) Home Phone: ( Primary Not Listed Contact Phone) ( ) Work Phone: ( Primary Not Listed Contact Phone) ( ) In Case of Emergency: Names of persons who can assume temporary responsibility and are authorized to pick up. Name Relationship Home Phone Work Phone Other Phone Name Relationship Home Phone Work Phone Other Phone Name Relationship Home Phone Work Phone Other Phone Name Relationship Home Phone Work Phone Other Phone Name Relationship Home Phone Work Phone Other Phone Name Relationship Home Phone Work Phone Other Phone Name Relationship Home Phone Work Phone Other Phone Siblings: List all siblings attending school in the Espanola School District. Name Gender Grade School Name Gender Grade School
EPS%20REGISTRATION%202017%20-%20Preschool%20(locked%20eps).docx