Student's Name*

First Name Middle Name Last Name

Date of Birth*

Date

Age*

Grade*

Phone Number*

Area Code Phone Number

Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Home School*

What technology devices does your child have access to? Check all that apply.*

Does the student have an Individualized Education Plan (IEP)?*

Yes No

Does the student have a 504 Plan?*

Yes No

Who does the student live with?*

Ex: Parents, Mom, Dad, Aunt, Uncle, etc.

Contact #1*

First Name Last Name

Relationship to Student*

Ex: Mom, Dad, Aunt, Uncle, etc.

Home Phone

Area Code Phone Number

Cell Phone*

Area Code Phone Number

Work Phone

Area Code Phone Number and Ext.

Contact #2

First Name Last Name

Relationship to Student

Ex: Mom, Dad, Aunt, Uncle, etc.

Home Phone

Area Code Phone Number

Cell Phone

Area Code Phone Number

Work Phone

Area Code Phone Number and Ext.

Contact #3

First Name Last Name

Relationship to Student

Ex: Mom, Dad, Aunt, Uncle, etc.

Home Phone

Area Code Phone Number

Cell Phone

Area Code Phone Number

Work Phone

Area Code Phone Number and Ext.

What hours are you mostly available to attend Zoom meetings, discuss your child's progress, etc.? Check all that apply.*

Student's Name*

First Name Last Name

Contact #1*

First Name Last Name

Relationship to Child*

Ex: Mom, Dad, Aunt, Uncle, etc.

Email*

example@example.com

How often do you check your email?*

Contact #2

First Name Last Name

Relationship to Child

Ex: Mom, Dad, Aunt, Uncle, etc.

Email

example@example.com

AT&T: number@mms.att.net

T-Mobile: number@tmomail.net

Verizon: number@vzwpix.com

Sprint: number@pm.sprint.com

Xfinity Mobile: number@mypixmessages.com

Virgin Mobile: number@vmpix.com

Tracfone: number@mmst5.tracfone.com

Simple Mobile: number@smtext.com

Mint Mobile: number@mailmymobile.net

Red Pocket: number@vtext.com

Metro PCS: number@mymetropcs.com

Boost Mobile: number@myboostmobile.com

Cricket: number@mms.cricketwireless.net

Republic Wireless: number@text.republicwireless.com

Google Fi (Project Fi): number@msg.fi.google.com

U.S. Cellular: number@mms.uscc.net

Ting: number@message.ting.com

Consumer Cellular: number@mailmymobile.net

C-Spire: number@cspire1.com

Page Plus: number@vtext.com

If your cellular carrier is not listed, try number@vzwpix.com

Contact #1

First Name Last Name

Relationship to Student

Ex: Mom, Dad, Aunt, Uncle, etc.

Text Alert Number

Example: 3345551489@mms.att.net

Contact #2

First Name Last Name

Relationship to Student

Ex: Mom, Dad, Aunt, Uncle, etc.

Text Alert Number

Example: 3345558532@tmomail.net

Houston County Schools Virtual Learning Program Student Information Form

Contact Information

Communication

Email Alerts

Text Alerts