Teacher Information Card This form includes student and parent information as well as those who are authorized to pick up said student. Step 1 of 5 20% Child #1Please fill in your child's information below. If there are siblings, please fill out the next child's information on the next page. If you have only one child attending, you may skip this section. First Name Middle Name Last Name GradeKindergarten1st Grade2nd Grade3rd Grade4th Grade5th GradeChild's Age Date of Birth (Month/Day/Year) Place of Birth Child's Physician Physician's Phone # List Any Allergies or Physical Difficulties Last School Attended Please list any medications the child is currently taking Child #2 (Sibling)Please fill in your 2nd child's information below. If there are more siblings, please fill out the next child's information on the next page. If you have only one child attending, you may skip this section. First Name Middle Name Last Name GradeKindergarten1st Grade2nd Grade3rd Grade4th Grade5th GradeChild's Age Date of Birth (Month/Day/Year) Place of Birth Child's Physician Physician's Phone # List Any Allergies or Physical Difficulties Last School Attended Please list any medications the child is currently taking Child #3 (Sibling)Please fill in your 3rd child's information below. If you have only one child attending, you may skip this section. First Name Middle Name Last Name GradeKindergarten1st Grade2nd Grade3rd Grade4th Grade5th GradeChild's Age Date of Birth (Month/Day/Year) Place of Birth Child's Physician Physician's Phone # List Any Allergies or Physical Difficulties Last School Attended Please list any medications the child is currently taking Address Home Phone Church Currently Attending Mother's Name Mother's Employer Mother's Cell # Mother's Work # Mother's Email Father's Name Father's Employer Father's Cell # Father's Work # Father's Email If parents are separated, with whom does the child reside? Name of Emergency Contact & Phone Number Addition Information that would be Helpful to the Teacher? Authorized Names for Student Pick-UpTo ensure the safety of all our students, CCCS has implemented the following checkout/carpool policy. We do not allow students to be picked up by anyone who is not on our pickup permission list. Please list below all who have permission to pick up your child(ren) on a regular basis, giving names, relationship, and contact number(s). The persons listed below will be the only ones to whom your child will be released. In the case of any emergency pickup by someone not on our list, or should your child be riding home with another student at CCCS, we would need written or verbal permission from the parents – no exceptions. These names will be on file in the School Administrator’s office.The following person(s) have my permission to pickup my child(ren):Person #1Name Relationship Home # Work # Cell # Person #2Name Relationship Home # Work # Cell # Person #3Name Relationship Home #