Byron-Bergen Central School District
  6917 West Bergen Rd., Bergen, NY 14416 Phone (585) 494-1220 Fax (585) 494-2613
  
Student Information Change Form 
STUDENT NAME: 	GRADE:	DOB:
STUDENT NAME: 	GRADE:DOB:
STUDENT NAME: 	GRADE:DOB:
STUDENT NAME: 	GRADE:DOB:
STUDENT NAME: 	GRADE:DOB:
STUDENT NAME: 	GRADE:DOB:
Address Change:	 Effective Date: 
OLD:	
NEW:

* Proof of Residency is required (Current Lease, Mortgage Statement, Pay Stub, Utility Bill)
Did the Whole Family Move?

(If No, Please Explain)

HOME:	OLD:	NEW:	
CELL:	OLD:	NEW:	
Telephone Number Change:	Effective Date:

WORK:	OLD:	NEW:

INSTANT CONNECT (Electronic Phone Messaging): The Byron-Bergen Central School District uses an electronic phone messaging system to contact families by phone of school closings, emergency notifications and event reminders. In the spaces below, please provide the phone number(s) you would like to receive calls at.
1)	OLD:	NEW:

2)	OLD:	NEW:
3)	OLD:  NEW:
	Email Change	Effective Date:

OLD:

	NEW: 
EMERGENCY CONTACT INFORMATION:
In the event of an emergency and the parent or guardian cannot be reached , I authorize the transport of my child to the nearest Emergency First Aid Station by ambulance, if necessary.  I realize that the school district cannot assume responsibility for the payment of medical fees or expenses incurred.  I authorize the School Nurse to obtain immunization, physical examination, injury, and/or illness information from my child’s Physician.

                   	Signature of Parent/Guardian	          Date
If necessary, I authorize the school to call :

Family Physician 	Phone #
If my child has to be taken home because of minor illness and the parent or guardian cannot be reached, please contact:
EMERGENCY CONTACTS:
1)
   	 Name
2)			Phone Number	
   	 Name
3)			Phone Number	
   	 Name
Preferred Hospital 
                                      
Family Dentist:
                                      			Phone Number	
	  Hospital Name             	  Address                                    Phone #		
		Name	  Address                                    Phone #		
	Print Name of Parent/Guardian	Date 

	Signature of Parent/Guardian 	Date