Student/Basic Information

Please complete all information requested on this form.

Student Legal First Namerequired

Student Legal Last Namerequired

Student Nick Namerequired

MSDA Graduation Yearrequired

Student Date of Birthrequired

Birthplace City, Staterequired

Street Addressrequired

Townrequired

Staterequired

Zip Coderequired

Countyrequired

Home Phonerequired

Student Cell Phonerequired

Student's Local Newspaper

Student's Local Media Website

Eighth Grade School & Townrequired

Student Lives With:required

Indicate Who Student Lives Withrequired

Primary Contact - Parent/Guardian Information

Person(s) with whom the student lives and has primary custody; Additional Parent/Guardian information is listed separately.

Primary Contact First Namerequired

(with whom the student lives)

Primary Contact Last Namerequired

(with whom the student lives)

Title (Mr., Mrs., Ms., etc.)required

Primary Contact Relationship to studentrequired

Indicate Primary contact:required

Primary Contact Emailrequired

Primary Contact Cell Phonerequired

Primary Contact Employerrequired

Employer Street Addressrequired

Employer City, State, Ziprequired

Work Phonerequired

Is there a 2nd Parent/Guardian?*

Yes No

Parent/Guardian #2 Relationship to studentrequired

Indicate Parent/Guardian relationshiprequired

Parent/Guardian #2 First Namerequired

Parent/Guardian #2 Last Namerequired

Title (Mr., Mrs., Ms., etc.)required

Parent/Guardian #2 Cell Phonerequired

Parent/Guardian #2 Emailrequired

Does 2nd Parent/Guardian live at separate address?*

Yes No

Parent/Guardian #2 Home Street Address, City, State, Ziprequired

Parent/Guardian #2 Employerrequired

Parent/Guardian #2 Employer Addressrequired

Parent/Guardian #2 Employer City, State, Ziprequired

Work Phonerequired

Non-Custodial Parent Information

Person(s) with whom the student DOES NOT live.

Please check Yes or No if there is Non-Custodial Parent Information*

Yes No

Non-custodial Relationship to studentrequired

Indicate Non-Custodial Relationship - Otherrequired

Non-Custodial First Namerequired

Non-Custodial Last Namerequired

Title (Mr., Mrs., Ms., etc.)required

Street Addressrequired

Townrequired

Staterequired

Zip Coderequired

Email Addressrequired

Home Phonerequired

Cell Phonerequired

Employer Namerequired

Employer Street Addressrequired

Employer City, State, Ziprequired

Work Phonerequired

Second Mailing*

Should this person receive a separate mailing?

Yes No

Notify Information

School Reach is the automated telephone calling service that is used to notify the Mount community of special announcements such as school closings or other important and timely information. Communication will be sent via email, voice, and text. Provide home and cell phone numbers as well as email address to receive alert notifications.

Primary Notify Emailrequired

Primary Email address – one which is checked on a REGULAR BASIS.

Primary Notify Phonerequired

Primary phone number – one which can receive text messages and phone calls/voice messages.

Primary Notify First & Last Namerequired

Primary Name Relationship to studentrequired

Indicate Primary Name Notify Otherrequired

Additional Contact Information to receive notifications (may include student cell to receive text alerts from school):

Notify Name

Notify Phone #1

Notify Name

Notify Phone #2

Notify Name

Notify Phone #3

Secondary Email

Additional Email

Emergency Contact Information

List contacts other than parents.

Emergency Contact #1 First Namerequired

Emergency Contact #1 Last Namerequired

Emergency Contact Relationship to studentrequired

Indicate Emergency Contact - Otherrequired

Emergency Contact #1 Cell Phonerequired

Emergency Contact #1 Work Phonerequired

Emergency Contact #1 Home Phonerequired

Emergency Contact #2 First Namerequired

Emergency Contact #2 Last Namerequired

Emergency Contact #2 Relationship to studentrequired

Indicate Emergency Contact #2 - Otherrequired

Emergency Contact #2 Cell Phonerequired

Emergency Contact #2 Work Phonerequired

Emergency Contact #2 Home Phonerequired

Code Red Information

In case of an emergency on school property.

Is your student a licensed driver?*

Yes No

Student Driver*

If student drives to school, would you allow her to drive herself directly home in the case of a Code Red emergency?

Yes No

Student Non-Driver*

If a non-driver, would you grant her permission to be driven home by another MSDA community member?

Yes No

Non-Driver Preference*

Would you prefer that your daughter remain in school until you or a person designated by you arrives? (Answer this question only if a non driver.)

Yes No

Sibling Information

Does your child have siblings?*

Yes No

Sibling Namerequired

Year of Birthrequired

Sibling Schoolrequired

If multiple siblings, provide additional information.

Sibling Name

Year of Birth

Sibling School

Sibling Name

Year of Birth

Sibling School

Alumnae Affiliation

Do you or your child know Mount graduates?*

Yes No

Alumna Namerequired

Graduation Yearrequired

Alumna Relationship to Studentrequired

If multiple alumnae, provide additional information:

Alumna Name

Graduation Year

Alumna Relationship to Student

Alumna Name

Graduation Year

Alumna Relationship to Student

Electronic Signature

Signaturerequired

Date Signedrequired (mm/dd/yyyy)