Student Questionnaires

STUDENT QUESTIONNAIRE

Purpose: The information collected on this form will be maintained in the student's educational record and used by school personnel to support academic planning, health and safety, and to coordinate services. All fields must be completed accurately. Submitting this form certifies that the information is true and complete to the best of your knowledge and that you authorize the school to use the information for educational purposes and to contact the persons listed in the event of an emergency.

Student Information

Preferred Name:     Date of Birth:     Student ID:

Primary Language(s):     Email:

Parent / Guardian Information

Relationship:     Phone:     Email:

Emergency & Medical Information

Relationship:     Phone:

Insurance Provider:     Policy Number:

  Student has an active IEP or 504 Plan     If yes, provide school case manager or coordinator:

Academic & Learning Profile

  Visual (charts, diagrams)       Auditory (lectures, discussion)       Kinesthetic (hands-on)       Reading / Writing       Other:

Technology & Transportation

Reliable internet access at home:   Yes       No

  Desktop/Laptop       Tablet       Smartphone       None

Permissions & Acknowledgments

Directory Information & Media Release: The school may include student name, grade level, and school-related photographs or work in internal directories and school publications unless you indicate objection by checking the opt-out box below.

  I consent to release of directory information and use of school photographs or work for school publications and internal communications.       I do NOT consent to directory or media release.

Field trip and activity-specific permissions will be requested separately. Signing this questionnaire does not constitute blanket authorization for off-campus or overnight trips.

Privacy, Data Use, and Certification

The information provided will be used for educational planning, health and safety, and to comply with legal obligations. The school may disclose information to staff with legitimate educational interest and to contracted service providers under written agreements that require confidentiality. The school will not disclose personally identifiable education records to third parties without written consent except as permitted by law. By signing below, the signer certifies that the information on this form is true and accurate, and agrees to notify the school promptly of material changes.

I acknowledge that knowingly providing false information or withholding material facts may result in administrative action. I authorize the school to contact the emergency contacts listed and to seek emergency medical treatment if necessary.

Signing Capacity (check one):
  I am the student and affirm I am 18 years of age or older.
  I am the parent or legal guardian signing for a minor student.

Additional Information (Optional)

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