Student Information Sheet
Period(s) _______
Student Name _____________________________________
Address __________________________________________
Home Phone _____________ I live with _________________
Mom’s Name ______________ Mom’s Work # ____________
Mom’s email _______________ Mom’s cell # ___________
Dad’s Name _______________ Dad’s Work # __________
Dad’s email _______________ Dad’s cell # ____________
Allergies, special needs or anything else Mrs. Mintz-Moreno needs to know to
help you make this a successful year:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
We have read the course requirements for Mrs. Mintz-Moreno's math/science
class, and accept the responsibility for meeting them.
__________________________ ___________________
(Parent Signature) (Student Signature)