Student Emergency and Medical Information
2017-2018

Please fill in all required areas; use "none" or "n/a" if the information does not apply to you.

In addition to this online form, current immunization records must be turned in at the front office prior to the first day of school.

Student Information
Student's First Name
Your answer
Student's Middle Name
Your answer
Student's Last Name
Your answer
Student's Preferred Name or Nickname
Your answer
Student's Cell Phone Number
Your answer
Student's Grade
Student's Date of Birth
MM
/
DD
/
YYYY
Street Address
Your answer
City
Your answer
State
Zip Code
Your answer
Parent's Information
Parent's Preferred Phone Number (to be published in directory)
Your answer
Parent's Email Address (to be published in directory)
Your answer
Father's Name
Your answer
Father's Cell Phone
Your answer
Father's Email Address
Your answer
Mother's Name
Your answer
Mother's Cell Phone
Your answer
Mother's Email Address
Your answer
Parent Name and Address (if different from student)
Your answer
Student resides with (please check all that apply):
Emergency Contacts
Other parties to contact in case of emergency when parents are not available.
First Emergency Contact Name
Your answer
Relationship with student
Emergency Contact Phone
Your answer
Second Emergency Contact Name
Your answer
Relationship with student
Emergency Contact Phone
Your answer
Medical Personnel
List student's doctors, dentist, etc.
Student's Primary Physician Name
Your answer
Primary Physician Phone Number
Your answer
Date of Last Physical
MM
/
DD
/
YYYY
Date of Last Tetanus Shot
MM
/
DD
/
YYYY
Student's Dentist Name
Your answer
Dentist Phone Number
Your answer
Insurance Information
Name of Health Insurer
Your answer
Policy/ID #
Your answer
Name of Insured
Your answer
Relationship to Student
Medical Notations
Please make any applicable medical notations regarding your child. Please type "none" or "n/a" if the questions are not applicable to your child.

It is the parent's responsibility to keep all information current throughout the entire school year. Please notify the office immediately if changes occur.

List all medications taken on a regular basis
Your answer
Indicate allergies to medications, foods, latex, insect stings, bites, etc.
Your answer
Indicate any relevant medical information (e.g. contact lens wearer, family history of sudden death, seizures, heart conditions, asthma, previous surgeries)
Your answer
Permissions
Please check all appropriate boxes
I hereby give my permission for this student to (check all that apply)
Required
Student-Parent Compliance Statement (Blue Book): I have read the rules and regulations (and penalties for their infraction) and agree to assist the school in seeing that my child abides both by the letter and by the spirit of them.
Emergency Information and Medical Treatment Consent
I recognize that as a result of participation in student activities, medical treatment on an emergency basis may be necessary and further recognize that school personnel may be unable to contact me for my consent for emergency medical care. I do hereby consent in advance to such emergency care, including hospital care, as may deemed necessary under the then existing circumstance. I accept full responsibility for any such treatment.
Name of Parent or Legal Guardian
Your answer
Date of consent given
MM
/
DD
/
YYYY
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