MARIEMONT CITY SCHOOL DISTRICT
Mariemont High School, Mariemont Jr. High, Fairfax Elementary, Mariemont Elementary, and Terrace Park Elementary
Mariemont High School
3812 Pocahontas Avenue
Cincinnati, OH 45227
(513) 272-7600 Fax (513) 527-8992 www.mariemontschools.org
Student’s Name _______________________________________ M _____ F _____ Date __________
Address ______________________________________________________ Telephone ___________
Street Community
Birthplace _________________________________________________________________________
City County State
Birth date ________________ Grade as of this date: _________ SS# _____________________
Father _____ Stepfather ____ Guardian ____ Mother ____ Stepmother _____ Guardian _____
Name _______________________________ Name __________________________________
Address _____________________________ Address ________________________________
Birthplace ___________________________ Birthplace ______________________________
Education ___________________________ Mother’s maiden name ____________________
Highest Grade Completed _______________ Education ____________ __________________
Employment _________________________ Highest Grade Completed __________________
Business Phone _______________________ Employment __ __________________________
Home Phone _________________________ Business Phone __________________________ Home Phone ____________________________
The student has:
Number of brothers: Older ____ Younger ____ Father Deceased _____ Mother Deceased ____
Number of Sisters: Older ____ Younger ____ Parents Separated ____ Parents Divorced _____
Who has legal custody of this child? _________ Parents Never Married ______
THE LAW REQUIRES THAT WE HAVE PROOF OF CUSTODY ON FILE. Custody papers in order ___________
Please note any special information that we should know about (medical problems, etc.)
_______________________________________________________________________________________________
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Ethnicity: Please check appropriate space. ______Asian/Pac Indian ______Black/Non Hispa
______Am Ind/Ala Nat ______White/Non Hisp ______ Hispanic ______Multiracial
Name and location of school last attended:
_______________________________________________________________________________
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Does your child have an I.E.P.? If yes, what category? ___________________________________
By my signature I attest that the above information is accurate to the best of my knowledge.
Signature of Parent/Guardian _________________________________________ Date _________
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For Office Use Only
School Building _________________ Student EMIS Number __________________