Summer School Registration 2019
Student First Name: *
Your answer
Student Last Name: *
Your answer
Home Phone Number *
Your answer
Student's Birthday *
MM
/
DD
/
YYYY
School the student will attend in 2019-20 *
Your answer
Grade level the student is CURRENTLY in *
Your answer
Home Street Address *
Your answer
City *
Your answer
Zip Code *
Your answer
Email Address *
Your answer
Select Course *
Select Course (Second Choice if taking more than 1 class)
Emergency Contact Information
Father/Guardian's Name
Please list first and last name.
Your answer
Father/Guardian's contact phone number
xxx-xxx-xxxx
Your answer
Father/Guardian's work phone number
xxx-xxx-xxxx
Your answer
Mother/Guardian's Name
Please list first and last name
Your answer
Mother/Guardian's contact phone number
xxx-xxx-xxxx
Your answer
Mother/Guardian's work phone number
xxx-xxx-xxxx
Your answer
Emergency Contact Person *
Your answer
Emergency Contact's phone number *
xxx-xxx-xxxx
Your answer
Emergency Contact Person (second person) *
Your answer
Emergency Contact's phone number (second person)
xxx-xxx-xxxx
Your answer
Health Information
I/we are aware the information provided and authorize the release of this information to appropriate school personnel.
Will your child require prescription medication during the hours they are attending summer school? *
If yes, please list any medications:
Your answer
If yes, a Physician's Order for Administration of Medication form will need to be completed. Forms are available in your child's school office or at the following link:

www.fonddulac.k12.wi.us/uploads/Physician_order_for_medication.doc

Please call School Health Programs with questions, 906-6548.

Physician's Name *
Your answer
Physician's phone number *
xxx-xxx-xxxx
Your answer
Dentist's name *
Your answer
Dentist's phone number *
xxx-xxx-xxxx
Your answer
List significant health problems or disabilities and appropriate action (e.g. asthma, bee sting allergy, seizures, etc.)
Your answer
Have you worked with a school nurse to develop a health care plan/emergency plan for this condition?
Procedures
Procedures followed in case of illness or injury:

1. Contact Parent/Guardian
2. Contact designated Emergency contact person
3. If unable to reach above individuals and situation warrants, call ambulance/physician
4. If severe illness or injury, call ambulance.

The information provided here is confidential information. Not for Distribution.
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