Damrine Gourdlen

[Damrine/Xhota ((Curi))]

STUDENT INFORMATION
Full Legal Name (Last/Family/Sur Name, First/Given Name, FULL Middle Name) [/size]
Gourdlen, Damrine, Marie

Preferred Name (If NOT First/Given Name) [/size]
Just Damrine

Former Last Names (If Applicable, Otherwise State ‘Not Applicable’) [/size]
N/A

Date of Birth and Time (mm/dd/yy, hh:mm AM/PM) [/size]
November 24 1994, 8:27 AM

Gender (Male/Female) [/size]
Female

Race (Place An ‘X’ Beside Any That Apply) [/size]

___American Indian
___Alaskan Native
___ Africa
___Asian
___Latin American
_x_American
___Pacific Islander
___Other (Specify) ______________

Ethnic Background

(Place An ‘X’ Beside Any That Apply) [/size]
___American Indian
___Alaskan Native
___ Africa
___Asian
___Latin American
_x_American
___Pacific Islander
___Other (Specify) ______________

US Social Security Number (If US Citizen, Otherwise State ‘Not Applicable’) [/size]
[Warning: Please DO NOT use yours, or anybody you know’s actually number]
583-29-4384

Address (Number and Street, City; State, Zip Code [If Not Applicable, Please indicate Otherwise]) [/size]
1765 West Seirra View Drive, Meadow Vista, 95722

E-Mail Address ( If Applicable, Otherwise State ‘Not Applicable’; [e-mail]) [/size]
[e-mail]

IM Address ( If Applicable, Otherwise State ‘Not Applicable’; list all current; username, site) [/size]
DamrineMG

Desired Email and IM Username (Username, Password) [/size]
[e-mail]
Parentsfail1124

Home Phone Number (If Applicable, Otherwise State ‘Not Applicable’; (Area Code) xxx-xxx) [/size]
[phone]

Cell Phone Number (If Applicable, Otherwise State ‘Not Applicable’; (Area Code) xxx-xxx) [/size]
(5300320-8765

HOUSEHOLD INFORMATION

Who Has Legal Custody? ( Place An ‘X’ Beside Any That Apply) [/size]
_x_Both Parents
___Father
___Mother
___Grandparent(s)
___Guardian(s)
___Ward of Court

Student Lives With (Place An ‘X’ Beside Any That Apply) [/size]
_x_Both Parents
___Father
___Mother
___Step Parent
___Grandparent(s)
___Guardian(s)
___Agency/Social Services
___Foster Parent(s)
___Alone
___Student’s Spouse/Partner
___Other Relative(s)

Parent/Guardian’s Legal Name (Last/Family/Sur Name, First/Given Name) [/size]
Robert and Natasha Gourdlen

Name Of Parent(s)/Sibling(s) Whom Attend/Have Attended Rosethorn Institute (Name, Relationship, Current Grade/Year Attended; [Indicate Graduation Date With An Asterisk (*)]
N/A_____________________________________
________________________________________
________________________________________
________________________________________



GAURDIAN INFORMATION

Name of Parents/Guardian NOT living in the primary household
(Only list Parents/Guardians that are authorized to have contact with student, but do not live in student’s primary household [Leave Blank If not Applicable]) [/size]
Legal Name: _________________________ Relationship to student: ______________________
Mailing Address: __________________________________________________________________
Place Of Business: ____________________________________________ Hours: ______________
Place Of Business Address: _________________________________________________________
Home Phone: (___)__________ Work Phone: (___)__________ Cell Phone: (___)__________

Legal Name: _________________________ Relationship to student: ______________________
Mailing Address: __________________________________________________________________
Place Of Business: ____________________________________________ Hours: ______________
Place Of Business Address: _________________________________________________________
Home Phone: (___)__________ Work Phone: (___)__________ Cell Phone: (___)__________

Legal Name: _________________________ Relationship to student: ______________________
Mailing Address: __________________________________________________________________
Place Of Business: ____________________________________________ Hours: ______________
Place Of Business Address: _________________________________________________________
Home Phone: (___)__________ Work Phone: (___)__________ Cell Phone: (___)__________


PREVIOUS SCHOOL(S) INFORMATION
Last School Attended Placer Elementary [/color] [/size]

Grade
1-8

Has your child ever been retained? (Yes or No If yes, what grade?) [/size]
No

Has student attended pre-school? (Yes or No If yes, check one of the following:) [/size]
_x_ PK-Public School
___Private Non-Profit PK
___Public Sponsored PK (Title 1)
___Private For Profit PK
___Head Start
___Other Public School
___PK Private School[/left]

List other schools student has attended:
Meadow Vista Preschool___________________________________
___________________________________________________________________________
___________________________________________________________________________

Has your child ever received any of the following services?

[/size] (If yes, check all that apply)
___Special Education* ___Gifted ___Speech* ___ESOL
___EIP Reading/Math ___Remedial ___OT/PT* ___504
(answer here)

*If student receives special education including speech or OT/PT, do you have a copy of a current IEP or IAP? [/size] (Yes or No) [/size]
(answer here)

HOME LANGUAGE SURVEY
Parent or Guardian must complete. [/color]
First Language learned by student?
English

Language student uses at home?
English

Language student uses most often?
English

Country of Origin?
America

Date entered US schools:
August 23 2000

LEGAL AGREEMENT[/size]

[x] By Checking This Box I Hereby Express My Understanding That
Rosethorn Institute For The Genetically Advanced Accepts Full
Responsibility For any harm done to students. I hereby surrende this child over to the evil clutches of The Headmaster unknowingly and lots other strange fine print I didn’t even read because I assumed this was just another stupid thing. I did not
actually read the small part about my student not being allowed to leave the campus unless permission is granted by The Headmaster himself (even though he would never agree to it) even though I said I read it and
agree to it.