Post by Hybrid on Mar 25, 2010 1:14:12 GMT -5
(unkown model and photogropher, but credit to them)
STUDENT INFORMATION
Full Legal Name (Last/Family/Sur Name, First/Given Name, FULL Middle Name) [/size]
Kai Kiba Tsume
Preferred Name (If NOT First/Given Name) [/size]
Former Last Names (If Applicable, Otherwise State ‘Not Applicable’) [/size]
Not Applicable
Date of Birth and Time (mm/dd/yy, hh:mm AM/PM) [/size]
October 8th 1992 3: 34 pm
Gender (Male/Female) [/size]
Male
Race (Place An ‘X’ Beside Any That Apply) [/size][/center]
___American Indian
___Alaskan Native
___ Africa
_X_Asian
___Latin American
___American
___Pacific Islander
___Other (Specify) ______________
Ethnic Background
___American Indian
___Alaskan Native
___ Africa
_X_Asian
___Latin American
___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]
946-56-3243
Address (Number and Street, City; State, Zip Code [If Not Applicable, Please indicate Otherwise]) [/size]
Not Applicable
E-Mail Address ( If Applicable, Otherwise State ‘Not Applicable’; something@somewhere.com) [/size]
Not applicable
IM Address ( If Applicable, Otherwise State ‘Not Applicable’; list all current; username, site) [/size]
Not Applicable
Desired Email and IM Username (Username, Password) [/size]
Kai hybrid34
Home Phone Number (If Applicable, Otherwise State ‘Not Applicable’; (Area Code) xxx-xxx) [/size]
Not Applicable
Cell Phone Number (If Applicable, Otherwise State ‘Not Applicable’; (Area Code) xxx-xxx) [/size]
Not Applicable
HOUSEHOLD INFORMATION
Who Has Legal Custody? ( Place An ‘X’ Beside Any That Apply) [/size]
___Both Parents
___Father
___Mother
___Grandparent(s)
___Guardian(s)
_X_Ward of Court
Student Lives With (Place An ‘X’ Beside Any That Apply) [/size]
___Both Parents
___Father
___Mother
___Step Parent
___Grandparent(s)
___Guardian(s)
___Agency/Social Services
___Foster Parent(s)
_X_Alone
___Student’s Spouse/Partner
___Other Relative(s)
Parent/Guardian’s Legal Name (Last/Family/Sur Name, First/Given Name) [/size]
Name Of Parent(s)/Sibling(s) Whom Attend/Have Attended Rosethorn Institute (Name, Relationship, Current Grade/Year Attended; [Indicate Graduation Date With An Asterisk (*)]
________________________________________
________________________________________
________________________________________
________________________________________
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 (Name) [/color] [/size]
Green Crest High School
Grade
Finished: 9th 10th
Attending:11Th
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]
___ PK-Public School
___Private Non-Profit PK
___Public Sponsored PK (Title 1)
___Private For Profit PK
___Head Start
_X_Other Public School
___PK Private School[/left]
List other schools student has attended:
Green Crest High School
Has your child ever received any of the following services?
___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]
HOME LANGUAGE SURVEY
Parent or Guardian must complete. [/color]
First Language learned by student?
Japanese
Language student uses at home?
English
Language student uses most often?
English
Country of Origin?
Japan
Date entered US schools:
August 7th 1997
LEGAL AGREEMENT[/size]
[X] By Checking This Box I Hereby Express My Understanding ThatRosethorn Institute For The Genetically Advanced Accepts FullResponsibility 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.