Student Information Online Form: Student Information Step 1 of 2 50% Student InformationName First Last Preferred Name or Nickname Birth Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*MaleFemalePrefer Not to AnswerEthnicity* Additional InformationProbation* Yes No Diversion* Yes No Truancy* Yes No Social Worker* Yes No Counselor* Yes No Therapist* Yes No Psychologist* Yes No Physician* Yes No Probation Officer Name Diversion Officer Name Truancy Officer Name Social Worker Name Counselor Name Therapist Name Psychologist Name Physician Name Tylonel/Ibuprofen allowed* Yes No Antacid/Cough drop allowed* Yes No Physical limitations/medical conditionsList all RXs and dosesRXDose Eligible for free/reduced lunch* Yes No Does student have access to an electronic device* Computer Tablet Does student have internet access to complete coursework?* Yes No T-Shirt Size* If your student is eligible, would they like to participate in the home school graduation ceremony?* Yes No HiddenWould 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
Edgenuity/Imagine Learning
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