Sanborn Regional High School Student Information 2018-2019
Student's First Name *
Your answer
Student's Last Name *
Your answer
Student's Gender *
Student's Place of Birth *
Your answer
Student's Date of Birth (mm/dd/yyyy) *
Your answer
Student's Current Grade (For the 2018-2019 School Year) *
Student's Primary Street Address *
Where he/she spends most nights.
Your answer
Student's Primary Town *
Your answer
Mailing Address (if different from above)
Your answer
What is your home (non-mobile) phone number?
If you only have mobile phones, leave this question blank.
Your answer
Contact Information
The responsible adults in our students' lives come in many varieties. Below, we use the "Mother" / "Father" designations for simplicity only. To help us reach you when we want to share news, ask a question, or reach you in an emergency, please use your best judgment filling this out.
Mother's Full Name
Your answer
Mother's Relationship to Student
Mother's Daytime / Mobile Phone
Please indicate the best number to use to reach you during the school day.
Your answer
Mother's Alternate Phone Number
Include this number if you may not be available at the number above.
Your answer
Mother's E-Mail Address
Your answer
Father's Full Name
Your answer
Father's Relationship to Student
Father's Daytime / Mobile Phone Number
Your answer
Father's Alternate Phone Number
Your answer
Father's E-Mail Address
Your answer
Has either the student or a parent moved or changed a phone number in the past year? YES OR NO *
This helps us quickly update our records year-to-year.
With Whom Does This Student Reside? *
Are there any special child custody provisions? *
If these provisions have recently changed, please contact the SRHS Guidance Office at 603-642-3600
SRHS Student Emergency Information Form
The information provided on this form will accompany your child to the hospital in a medical emergency. Please read and complete all areas of this form. Once submitted, you will receive a print-out of this information from the school which must be signed and returned to the main office.
Alternate #1: The name of a neighbor or relative who will assume temporary care of your student if you cannot be reached *
Your answer
Alternate #1: The address of the neighbor/relative *
Your answer
Alternate #1: The relationship the alternate #1 contact has to the student *
Your answer
Alternate #1: The cell phone of the alternate contact #1 *
Your answer
Alternate #1: The home phone of the alternate contact #1 *
Your answer
Alternate #2: The name of another neighbor or relative who will assume temporary care of your student if you cannot be reached *
Your answer
Alternate #2: The relationship the alternate #2 contact has to the student *
Your answer
Alternate #2: The address of the neighbor/relative *
Your answer
Alternate #2: The cell phone of the alternate contact #2 *
Your answer
Alternate #2: The home phone of the alternate contact #2 *
Your answer
Please use this space to list any routine daily medications the student takes (include name and dosage amounts)
Your answer
Please use this space to list any known allergies (food, drug, environmental) the student has
Your answer
Please use this space to describe any health conditions the student has
Your answer
What is the student's physician's name? *
Your answer
The city/town where the physician's office is located *
Your answer
Physician's office phone number *
Your answer
Dentist's office phone number
Your answer
What is the student's dentist's name?
Your answer
The city/town where the dentist's office is located
Your answer
What is your hospital of choice for emergency transport? *
Your answer
By printing your name in the box below, you recognize that the information on this form may be shared with school staff and emergency personnel as appropriate. It is the parent’s / guardian’s responsibility to share the students’s medical condition and treatment with transportation personnel (bus drivers). *
Your answer
By printing your name in the box below, you recognize the following: In case of accident or serious illness, I request the school to contact me. If the school is unable to reach me, I hereby authorize the school to call the physician indicated and follow his or her instructions. If it is impossible to contact the physician, the school may make whatever arrangements seem necessary. *
Your answer
The health office will stock the following medications and will administer those checked off by a parent or guardian. These will be administered according to the package directions at the discretion of the school nurse. THIS FORM WILL BE IN EFFECT FOR THE CURRENT SCHOOL YEAR. Please place an “X” in front of those medications the school nurse may administer to your child.NOTE: If a parent / guardian requests administration of non-prescription medication not noted in the above list, the medication should be brought to the Health Office in the original container by a parent / guardian and a Hold Harmless form should be completed. *
Required
By printing my name below, I, the parent/guardian, authorize the school administrator to direct members of the school staff to assist my child in taking the above medication and agree that I will not hold liable, any member of the school staff or an individual of official capacity who is directed by me (parent / guardian) and the school administrator to assist my child in taking said medication. *
Your answer
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