LIGHTHOUSE BAPTIST ACADEMY Carr. 3 Km 57.2 Barrio Quebrada Seca Ceiba PR  00735 (787)885-3755 www.lbaceiba.com GRADE (Grado):_____________ STUDENT’S NAME (Nombre del estudiante):______________________________________________ BIRTHDATE (Fecha de Nacimiento):_________________________          AGE (Edad) ____________ SSN (Número de Seguro social):_____________________________ RESIDENTIAL ADDRESS: ____________________________________________________________ (Dirección Residencial)           ____________________________________________________________ ____________________________________________________________ MAILING ADDRESS IF DIFFERENT: ___________________________________________________ (Dirección Postal si es diferente)          _____________________________________________________                                                                              ____________________________________________________ E-MAIL ADDRESS (Correo electrónico) :_________________________________________________ TELEPHONE NUMBER (Número de Teléfono):________________CELLULAR (Celular) __________________ FATHER’S OR TUTOR’S NAME (Nombre del Padre o Tutor): _______________________________ OCCUPATION (Ocupación):_____________WORK TELEPHONE (Teléfono del Trabajo):____________ MOTHER’S NAME (Nombre de la Madre):________________________________________________ OCCUPATION (Ocupación):_______________WORK TELEPHONE (Teléfono del trabajo) ___________ NAME, ADDRESS AND TELEPHONE NUMBER OF THE PERSON IN CHARGE OF THE STUDENT WHILE PARENT IS AT WORK:  (Nombre, dirección y número de teléfono de la persona encargada del estudiante mientras sus padres trabajan): NAME                                                  ADDRESS                                                         TELEPHONE NUMBER (Nombre)                                   (Dirección)                                                          (Número de Teléfono) ______________________      ____________________________________     __________________                                                   ____________________________________ STUDENT LIVES WITH (Estudiante vive con):  FATHER (Padre):______MOTHER (Madre):_____ BOTH (Ambos):________                 OTHER (Otro):_______ HOW MANY PEOPLE LIVE IN THE HOUSE?  (¿Cuantas personas viven en la casa?): ___________ WRITE THE FOLLOWING INFORMATION (Escriba la siguiente información): NAME                                                                        RELATIONSHIP                                           AGE (Nombre)                                                         (Parentesco)                                                    (Edad) _________________________________      ________________________________        ________ _________________________________      ________________________________        ________ _________________________________      ________________________________        ________ _________________________________      ________________________________        ________ _________________________________      ________________________________        ________ _________________________________      ________________________________        ________ PERSON TO CALL IN CASE OF EMERGENCY (Persona para llamar en caso de emergencia): NAME (Nombre): _________________________TELEPHONE (Número de Teléfono):_____________ STUDENT’S DOCTOR (Doctor del Estudiante):____________________________________________ STUDENT’S ALLERGIES (Alergias del estudiante):_________________________________________ ____________________________________________________________________________________ STUDENT’S DESEASES (Enfermedades del estudiante):_____________________________________ ____________________________________________________________________________________ PERSONS AUTHORIZED TO PICK UP THE STUDENT (Personas autorizadas para recoger al estudiante): ______________________________________________ ______________________________________________ _____________________________________________ I COMMIT MYSELF TO COOPERATE WITH THE PRINCIPAL TO FOLLOW THE RULES ESTABLISHED BY LIGHTHOUSE BAPTIST ACADEMY.    (Me comprometo a cooperar con el director  a seguir las reglas establecidas por Lighthouse Baptist Academy). ___________________________________              ____________________________________ FATHER’S SIGNATURE                                         MOTHER’S SIGNATURE (Firma Del Padre)                                                       (Firma de la Madre)

B.  HEALTH HISTORY (Serious Illnesses/Injuries: explain) _____________________________
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(Attach narrative if additional space needed)__________________________________________
C. LABORATORY (AS INDICATED)    Hemoglobin__________Urinalysis________________
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Name____________________________________Title_________________________________
Address_______________________________________________________________________
(Please Print)
Authorized Signature________________ Date __________

                         

   

 

 
 
                 

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