Blue Sheet Survey

WELCOME!

Dear Parents/Guardians:

Welcome to Middle School of Media, Law & Fine Arts!

Please fill out this mandatory survey in order to communicate essential information to Middle School of Media, Law & Fine Arts, especially Accepted Student Orientation and Freshman Orientation. As a reminder, you will need the following information:

• Student Biographical Data:
Name, Home Address, Email, Home Phone, Cell Phone, Student ID/OSIS number (Public school students can get this from their guidance counselor. Private school students, use 888888888), Date of Birth, Gender, and Ethnicity.

• Emergency Contact Information (Blue Card Information):
In the event of an emergency where we cannot reach the parent/guardian of record, choose three people who can get to Middle School of Media, Law & Fine Arts to pick up a sick/injured student. All contact information is required for each of the people selected.

Reason for Blue Card

Answer Required

New Student

Update Student's Information

Other:

Emergency Contact

Student's - First Name*

Answer Required

Middle Initial

Answer Required

Student's - Last Name*

Answer Required

Student's Date of Birth*

Answer Required

Student's ID#/OSIS#

Answer Required

1st Parent/Guardian - Contact Information

Parent/Guardian Name (Student resides with):*

Answer Required

Relationship*

Answer Required

Parent's Preferred Language of Communication

Written*

Answer Required

Oral

Answer Required

Home Telephone*

Answer Required

Work Telephone

Answer Required

Cell Number

Answer Required

Address

Street Address*

Answer Required

Apt.

Answer Required

Borough

Answer Required

Zip/Postal

Answer Required

Other Parent/Guardian

Parent/Guardian Name:

Answer Required

Relationship

Answer Required

Preferred Language of Communication

Written

Answer Required

Oral

Answer Required

Home Telephone

Answer Required

Work Telephone

Answer Required

Cell Number

Answer Required

Address

Street Address

Answer Required

City

Answer Required

Zip/Postal

Answer Required

List below names if two (2) persons who may be called in case of emergency or if child is sick in school

Name:*

Answer Required

Number*

Answer Required

Relationship *

Answer Required

2nd Name:

Answer Required

Number

Answer Required

Relationship

Answer Required

If there is a person who may NOT HAVE ACCESS to child, please indicate:

Name

Answer Required

Relationship

Answer Required

Order of Protection Exists

Answer Required

Yes

Health Information

Name of Physician/Clinic

Answer Required

Telephone

Answer Required

Health Alert

Does child have any health condition that may affect participation in physical activities?*

Answer Required

Yes

Allergies

Answer Required

Limitations

(e.g. stair climbing, participation in gym)

Answer Required

504 Services for the current year*

Answer Required

Yes

My child has:*

Answer Required

Private Health Insurance

Medicaid

No Health Insurance

If " No Health Insurance", are you willing to share contact information from this card to learn about insurance options?

Answer Required

Yes

If none of the named contacts can be reached, what do you wish the school to do if your child is sick or injured?*

It is understood that in the final disposition of an emergency case, the judgement of the school authorities with prevail. The recommendation of the parent as indicated above will be respected as far as possibble

Answer Required

Siblings

Name:

Answer Required

School of Attendance

Answer Required

2nd Name:

Answer Required

School of Attendance

Answer Required

3rd Name:

Answer Required

School of Attendance

Answer Required

LEGAL AFFIRMATION

By typing in my name below, I affirm that I am the parent / legal guardian of the student whose information has been submitted via this electronic survey.*

Answer Required

Today's Date

Answer Required

Please fix the highlighted areas below before submitting.

Blue Sheet Survey

Emergency Contact

LEGAL AFFIRMATION