MARIEMONT CITY SCHOOL DISTRICT
Mariemont High School, Mariemont Jr. High, Fairfax Elementary, Mariemont Elementary, and Terrace Park Elementary
Terrace Park Elementary School
723 Elm Street
Terrace Park, Ohio 45174
(513) 272-7700 Fax (513) 831-1249 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:
_______________________________________________________________________________
_______________________________________________________________________________
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 __________________