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HOUSEHOLD INFORMATION FORM

Bentworth School District

Household Information Form

Date:*

Answer Required

School:*

Answer Required

Bentworth Elementary School

Bentworth Middle School

Bentworth High School

Student's Legal First Name*

Answer Required

Student's Legal Middle Name

Answer Required

Student's Legal Last Name*

Answer Required

Date of Birth*

Answer Required

Grade:*

Answer Required

Do you have other children enrolled in the Bentworth School District who live in the same household for at least 50% of the time??*

Answer Required

YES

If "yes", please complete the information below:

First and last name of ALL children, School that they attend, Grade

Answer Required

Parent Notification

By law, each parent has equal rights and access to their child and their child's school records, UNLESS a parent provides Bentworth School District with a court order that indicates otherwise. The school MUST HAVE A COPY OF THE CURRENT COURT ORDER on file.

In cases of seperation / divorce, who has primary custody?

Answer Required

Is there a legal custody agreement?

Answer Required

Yes

Parent / Guardian Signature*

Answer Required