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Byron-Bergen Central School
Student Information Update Page


Please enter Student First, Middle and Last Name and update the following information as needed:

Student ID 
Student First Name
Student Middle Name
Student Last Name
Year of Graduation
Gender Male Female
Ethnicity
Date of Birth
Birth City
Birth State
Birth Country
For Transportation Purposes:
Student Lives with
For Transportation Purposes:
In Which County?
Primary Parent/Guardian
(and Spouse) Name(s)
Primary Parent/Guardian
Physical Address
Primary Parent/Guardian
Mailing Address (if different)
Primary Parent/Guardian
Place of Employment
Home Phone
Work Phone
Cell Phone
Pager Number
Email Address
Spouse
Place of Employment
Home Phone
Work Phone
Cell Phone
Pager Number
E-mail Address
Second Parent/Guardian
Place of Employment
Home Phone
Work Phone
Cell Phone
Pager Number
Email Address
Spouse
Place of Employment
Home Phone
Work Phone
Cell Phone
Pager Number
E-mail Address
Emergency Contact Name
Emergency Contact Phone Number:
Relationship to Student

Other Emergency Related Information:

Family Physician
Physician Address
Physician Phone
Preferred Hospital
Hospital Address
Hospital Phone
If applicable, please complete the following:
My child has the following allergies:
My child has the following condition
which requires special handling:
List serious illnesses, injuries, operations
in the last year
Are there any hearing difficulties?
Does your child have tubes in his/her ears? 
Does your child wear glasses?
Does your child wear contact lenses?
When are the glasses to be worn?
Are there any eye or visual difficulties?
My child routinely takes
the following medication(s):
Were there any immunizations given
in the last year that the Health Office was
not informed of?  Give exact dates.

Revised: 08/26/10