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WEHS Student Health Information Q2
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Email *
Date *
MM
/
DD
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YYYY
Date of Birth *
MM
/
DD
/
YYYY
Age *
First Name *
Middle Initial *
Last Name *
Street Address *
Town *
State *
Zip Code *
Mother/Legal Guardian Name:
Mother/legal guardian Phone Number
Mother/legal guardian  Work Phone Number
Mother/legal guardian  Address (if same as student, write "Same")
Father/Legal Guardian Name
Father/legal guardian  Phone Number
Father/legal guardian  Work Phone Number
Father/legal guardian  Address (if same as student, write "Same")
In case of emergency, who should be called first?
Clear selection
Who does the student actually live with? *
If the student has any medical conditions, please list and describe below
If the student has any allergies, please list and describe below
Students 18 or over may answer the following question, students under 18 must have a parent or legal guardian answer the following question.
Do you give permission for the student to receive, Tylenol, ibuprofen or cough drops? *
Health Insurance Provider (optional)
Health Insurance Policy number (optional)  
In the case of a serious illness or accident, the school will take whatever emergency actions are deemed necessary.  The parent or legal guardian will be called after emergency action has been taken (e.g. calling 911).  In non-emergency situations, the parent or legal guardian will be contacted.
Typing in your name indicates a verification and consent to the information provided in this form.
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