Bradford Academy
6th grade
Student Information Card
Please fill this out as complete as possible.  Print out a copy for your records.  Thank you.
Homeroom Teacher Grade
Student Last Name
First Name
Date of Birth
Gender
Parent/Guardian Information
Guardian's Last Name
Guardian's First Name
Home Phone
Work Phone
Cell Phone
Relation to Student
Email
Guardian's First Name
Guardian's Last Name
Work Phone
Home Phone
Cell Phone
Relation to Student
Email
Emergency Contacts
Relation to Student
Primary Contact Name
Home Phone
Work Phone Cell Phone
Relation to Student
Secondary Contact Name
Cell Phone
Home Phone Work Phone
Health Concerns
Medical
Emotional
Cognitive
Other Information
Siblings or close relative's name attending Bradford Academy
Relation to Student
Media Recording
During the school year, students may be photographed and/or video taped at Bradford Academy. Such use includes the display, publication, or otherwise use of photographs, images, and/or video taken of your child/children for use in printed materials such as brochures and newsletters, videos, and digital images such as those on the Bradford Academy website. Also, these images may be used for teacher self-analysis, and/or educational purposes. If you do not wish your child’s image to be printed, please check the box below indicating those wishes. I do understand that my child’s last name will not be used in conjunction with any video or digital images.
A check in this box indicates that I deny permission to use my child’s image on any type of media source at Bradford at any time. If this box is not checked, we have your permission to use your child’s image on any media source at Bradford.
Name of person who filled out this form
Relation to Student Todays Date