Student Information Change Request Form

1.	Student(s)*
	First Name   Last Name   Grade   School Building   Student Have IEP Student 1       --Please Select--K1st2nd3rd4th5th6th7th8th9th10th11th12th   --Please Select--High SchoolMiddle School Mt Rock ElemNewville ElemOak Flat Elem   --Please Select--YesNo Student 2       --Please Select--K1st2nd3rd4th5th6th7th8th9th10th11th12th   --Please Select--High SchoolMiddle School Mt Rock ElemNewville ElemOak Flat Elem   --Please Select--YesNo Student 3       --Please Select--K1st2nd3rd4th5th6th7th8th9th10th11th12th   --Please Select--High SchoolMiddle School Mt Rock ElemNewville ElemOak Flat Elem   --Please Select--YesNo Student 4       --Please Select--K1st2nd3rd4th5th6th7th8th9th10th11th12th   --Please Select--High SchoolMiddle School Mt Rock ElemNewville ElemOak Flat Elem   --Please Select--YesNo Student 5       --Please Select--K1st2nd3rd4th5th6th7th8th9th10th11th12th   --Please Select--High SchoolMiddle School Mt Rock ElemNewville ElemOak Flat Elem   --Please Select--YesNo Student 6       --Please Select--K1st2nd3rd4th5th6th7th8th9th10th11th12th   --Please Select--High SchoolMiddle School Mt Rock ElemNewville ElemOak Flat Elem   --Please Select--YesNo

	Parent/Guardian Name Change

2.	Previous Name

3.	New Name

	Phone Number/Email Address Change

4.	Do you wish to initiate any other changes of information? If a field is left blank, information will not be changed. If you wish to remove current information, please enter BLANK in the field.
	First Name   Last Name   Email Address   Main Number   Alternate Number   Global Connect Number Parent/Guardian 1             Parent/Guardian 2

	Emergency Contact Changes

5.	Name of Emergency Contact(s) to be removed
	First name   Last Name Contact Name     Contact Name     Contact Name

	Biological parents cannot be deleted without legal documentation of restricted or terminated parental rights.

6.	Emergency Contact(s) to be added
	First Name   Last Name   Phone Number   Relationship Contact Information         Contact Information         Contact Information

7.	Are there any other changes you would like to make or other information you would like to share with us?
	Are there any other changes you would like to make or other information you would like to share with us? YesNo

8.	Please explain:

9.	Parent Name/Signature*

10.	Contact Phone Number if the registrar has questions

11.	Contact Email Address