Western Wisconsin-Upper Michigan

PLEASE PRINT

NAME: ______________________________________________________________

                    (Last)                                         (First)                     (M.I.)

HOME ADDRESS:           ____________________________________________________                                                                                                             (Street)

                              _____________________________________________________

                                 (City)                                (State)                   (Zip Code)

HOME TELEPHONE: ________________________          GENDER:     M        F

ALTERNATE/SUMMER/MAILING ADDRESS:

                                        _______________________________________________

                                                            (Street or P.O. Box)

                                       _______________________________________________

                                        (City)                                (State)                   (Zip Code)

TEACHER'S E-MAIL ADDRESS: __________________________________________

SCHOOL: ___________________________________________________________

SCHOOL ADDRESS:          _______________________________________________

                                                            (Street or P.O. Box)

                                        _______________________________________________

                                   (City)                                (State)                   (Zip Code)

SCHOOL TELEPHONE: _______________________ FAX: ______________________

HEALTH CONCERNS/SPECIAL NEEDS: ___________________________________

_____________________________________________________________________

PRINCIPAL'S SIGNATURE: ______________________________________________

                                                                                                              (Date)