Secondary Student Health Data Form
This form allows students at Pioneer Technology Center (PTC) to share health information and contact information which will only be used by staff members in the case of an emergency. An opportunity to opt out of medical treatment is also provided.
Email address *
POLICY OF NON-DISCRIMINATION
Pioneer Technology Center does not discriminate on the basis of race, color, national origin, sex/gender, age, religion, disability, or veteran status. Inquiries concerning application of this policy should be made to Karl Lynes or Pam Dickerson, Co–Compliance Officers at (866) 612-4782 or at 2101 N. Ash, Ponca City, OK 74601
Student's First Name *
Your answer
Student's Last Name *
Your answer
Partner High School *
Student's Street Address
Your answer
City/State
Your answer
Zip Code
Your answer
Parent/Guardian # 1 Name *
Your answer
Parent/Guardian # 1 Primary Phone (Format: 580.762.8336) *
Your answer
Parent/Guardian # 1 Other Phone (Format: 580.762.8336)
Your answer
Parent/Guardian # 2 Name
Your answer
Parent/Guardian # 2 Primary (Format: 580.762.8336)
Your answer
Parent/Guardian # 2 Other Phone (Format: 580.762.8336)
Your answer
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