Student Information Form 2025-2026

Please complete this form for each child you have enrolled at Diller-Quaile. During the school year any changes to this information should be submitted in writing.

Student information

Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian #1

First Name

Last Name

Cell Phone #1

(###)

###

####

Parent/Guardian #2

First Name

Last Name

Cell Phone #2

(###)

###

####

Indicate any medical conditions, allergies, or special needs that your child may have:

Adult Contact and Dismissal Information

Name of person(s) responsible for accompanying your child or meeting your child at dismissal: Please include Name, Relationship to Child, and Day/Cell Phone

Emergency Information

Name of person to be contacted if parent/guardian is unavailable

First Name

Last Name

Emergency Contact's Phone Number

(###)

###

####

Pediatrician Name

First Name

Last Name

Pediatrician Phone Number

(###)

###

####

Address of Pediatrician

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

In the event of an emergency or the unavailability of a parent or designee, I give consent for The Diller-Quaile School of Music to take whatever actions it, in its discretion, deems necessary for the health of my child, including without limitation obtaining first aid by emergency medical services personnel and/or transporting my child to receive emergency care.

By clicking this box, you agree to the statement above