Name of Student Shadowing:

Parent(s)/Guardian(s):

Address:

City: Zip Code:

Phone Number:

Email address:

Grade:

Grade School :

Name of Emergency Contact:

Emergency Contact Phone Number:

Parent Cell Phone Number:

Mr. Kevin Charpentier will email you with your shadow date. If you have any questions please contact Mr. Kevin Charpentier by phone at 708.344.0404 or by .