Student Information Online Form: Student InformationStep 1 of 250%Student InformationName First Last Preferred Name or NicknameBirth Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*MaleFemalePrefer Not to AnswerEthnicity*Additional InformationProbation* Yes NoDiversion* Yes NoTruancy* Yes NoSocial Worker* Yes NoCounselor* Yes NoTherapist* Yes NoPsychologist* Yes NoPhysician* Yes NoProbation Officer NameDiversion Officer NameTruancy Officer NameSocial Worker NameCounselor NameTherapist NamePsychologist NamePhysician NameTylonel/Ibuprofen allowed* Yes NoAntacid/Cough drop allowed* Yes NoPhysical limitations/medical conditionsList all RXs and dosesRXDose Eligible for free/reduced lunch* Yes NoDoes student have access to an electronic device* Computer Tablet Does student have internet access to complete coursework?* Yes NoT-Shirt Size*If your student is eligible, would they like to participate in the home school graduation ceremony?* Yes NoThis field is hidden when viewing the formWould you like to begin the next form?* Yes, begin the next form. No, I will begin the next form later.Your next form is: Student Handbook Acknowledgement