SAMPLE

XYZ Charter

719 Fourth Street

Anytown, TX

555/555-1234

20__-20__ Directory Information

Please complete the information you wish to include in the directory. If your child is a member of a multi-household family, please include the child’s primary residence information and the secondary residence information if you wish to have it included in the directory.

Please print legibly in black ballpoint ink.

Parent Information

Primary Residence Information

Name (Last, First) ___________________________________________________________________

Relationship to Student ___mother ___father ___step-mother ___step-father ___other

Name (Last, First) ___________________________________________________________________

Relationship to Student ___mother ___father ___step-mother ___step-father ___other

Street Address ______________________________________________________________________

City, State, Zip _____________________________________________________________________

Home Phone __________________________ E-mail _______________________________________

Secondary Residence Information

Name (Last, First) ___________________________________________________________________

Relationship to Student ___mother ___father ___step-mother ___step-father ___other

Name (Last, First) ___________________________________________________________________

Relationship to Student ___mother ___father ___step-mother ___step-father ___other

Street Address ______________________________________________________________________

City, State, Zip _____________________________________________________________________

Home Phone __________________________ E-mail_______________________________________

Student 1:

Child’s Name (Last, First, M.I.) ________________________________________________________

Grade _________________________ Alternate Phone ______________________________________

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Student 2:

Child’s Name (Last, First, M.I.) ________________________________________________________

Grade ______________________ Alternate Phone _________________________________________

Student 3:

Child’s Name (Last, First, M.I.) ________________________________________________________

Grade ______________________ Alternate Phone _________________________________________

Student 4:

Child’s Name (Last, First, M.I.) ________________________________________________________

Grade ______________________ Alternate Phone _________________________________________

Student 5:

Child’s Name (Last, First, M.I.) ________________________________________________________

Grade ______________________ Alternate Phone _________________________________________

Exclusion Request

I, ____________________________, parent/guardian of _________________________wish to remain unlisted in the directory. I understand that my child(ren)’s name(s) will be included in the class list but no other information will be included.

Signature:________________________________________Date:___________________

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