HIPAA
Compliance
Student #2 Legal Name First Name Middle Name Last Name Student #2 Date of Birth Date Student #2 Gender at Birth Male Female Student #2 Grade Level Please Select 9101112 Student #2 Personal Phone Number Area Code Phone Number Student #2 New to AJ? Yes No Student #2 Previous School if Applicable: School Name, City, State Student #2 Rides bus? Yes No Student #3 Legal Name First Name Middle Name Last Name Student #3 Date of Birth Date Student #3 Gender at Birth Male Female Student #3 Grade Level Please Select 9101112 Student #3 Personal Phone Number Area Code Phone Number Student #3 New to AJ? Yes No Student #3 Previous School if Applicable: School Name, City, State Student #3 Rides bus? Yes No Student #4 Legal Name First Name Middle Name Last Name Student #4 Date of Birth Date Student #4 Gender at Birth Male Female Student #4 Grade Level Please Select 9101112 Student #4 Personal Phone Number Area Code Phone Number Student #4 New to AJ? Yes No Student #4 Previous School if Applicable: School Name, City, State Student #4 Rides bus? Yes No
Emergency Contact #1 First Name * Last Name * Phone #1 Area Code * Phone Number * Phone #2 Area Code Phone Number Can this person pick up your student/s? Please Select YesNo * Relationship to student: Please Select GrandparentAunt/UncleCousinFamily FriendSiblingOther *
Emergency Contact #2 First Name Last Name Phone #1 Area Code Phone Number Phone #2 Area Code Phone Number Can this person pick up your student/s? Yes No Relationship to student: Please Select GrandparentAunt/UncleCousinFamily FriendSiblingOther