ECAPCS – Home

Student Information

*Students Last Name:

*Student’s First Name:

*Student’s Middle Initial:

*Student’s DOB:

*Home Address:

*Apt #:

*Zip Code:

*Home Phone:

*Has your child received Special Ed Services:
Yes: No:

*Gender:
Male: Female:

Ethnicity:

*Name of Parent/Guardian with whom child lives:

*Are you a DC resident?:
Yes: No:

*Is your current address a temporary living arrangement?:
Yes: No:

*Is this temporary living arrangement due to loss of housing or economic hardship?:
Yes: No: N/A:

*Cell Phone:

*Work Phone:

*E-mail Address:

*Name of 2nd Parent/Guardian:

*Address – if different than above:

*Home Phone – if different than above:

*Cell Phone:

*Work Phone:

*E-mail Address:

*List any of your child’s medical concerns of which the school should be aware:

*List any medications that your child requires of which the school should be aware:

*List all food allergies and other allergies that your child has: