

1- ÉLÈVE
NOMPrénom(s)

  !

"##$
%&'' '()$*
2- RESPONSABLES LÉGAUX
MÈRE $*
#+,
# '
"
"-
%-.
/ 0
"
1&
1&2
1&-

3!

4-
3)&'&,$*
PÈRE$*
#
"
"-
%-.
/ 0
"
1&
1&2
1&-

3!

4-
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3)&'&,$*

. 25#(6-575%525"
3- AUTRE RESPONSABLE LÉGAL (PERSONNE PHYSIQUE OU MORALE)
$* 
'
"-
 -
!

"
1&
1&2

3)&'&,$*
Responsables légaux : Il est important de renseigner le document concernant les deux responsables légaux pour :
- La transmission des résultats scolaires (circulaire n
0
94-149 du 13/04/1994)
- Les élections des représentants des parents d'élèves : chaque parent est désormais électeur et éligible (note de
service n
0
2004-104 du 25/06/2004)
4- PERSONNES À APPELER EN CAS D'URGENCE ET/OU AUTORISÉES À PRENDRE L'ENFANT À
LA SORTIE
PERSONNE 1
#
 -
8 '
9 -

"
1&
1&2
PERSONNE 2
#
 -
 '
9 -

"
1&
1&2
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5- ASSURANCE :
:2$*
*$*
'3
3
1-''2'
; ''9'&',<,&
7
0'
=>
0'
=>
6?  0@,@,ABC=
*-A2>D+.EFG" H@? 
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