2020-2021 Nurses Emergency Information - Old Rochester Regional High School
Email address *
Student Name: *
Student DOB: *
MM
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DD
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YYYY
Primary Address (Include City/Town & Zip Code): *
Grade *
Bus Number *
Preferred Phone Number: *
Parent/Guardian #1 Name: *
Parent/Guardian #1 Custody: *
Parent/Guardian #1 Address (if different than student) *
Parent/Guardian #1 Employer:
Parent/Guardian #1 Email address: *
Parent/Guardian #1 Cell Phone: *
Parent/Guardian #1 Work Phone:
Parent/Guardian #2: (If non applicable please write n/a) *
Parent/Guardian #2 Address (if different than student) *
Parent/Guardian #2 Custody: *
Parent/Guardian #2 Employer:
Parent/Guardian #2 Email address:
Parent/Guardian #2 Cell Phone:
Parent/Guardian #2 Work Phone:
Does this student have health insurance? *
Health Insurance Company :
Health Insurance Policy Number:
*Please indicate names of others who will assume responsibility and provide transportation for your child in case of illness/injury/emergency. Emergency Contact #1 Name: *
Emergency Contact #1 Relationship to Student: *
Emergency Contact #1 Phone: *
Emergency Contact #2 Name: *
Emergency Contact #2 Relationship to Student: *
Emergency Contact #2 Phone: *
Student Physician's Name: *
Student Physician's Phone Number: *
Student Dentist's Name: *
Student Dentist's Phone Number:
Conditions that pertain to my child ***Please check all that apply: *
Required
Does this student have any environmental allergies? *
Does this student have any food allergies? *
Does this student have any medication allergies? *
Age of Majority: If your student turns 18 during the school year, he/she authorizes the following: *
Student electronic signature: *
I understand that this information is confidential, however, federal law permits information in the school health record to be shared with school officials on a ‘need to know’ basis and with a very limited number of other persons, including those who may need to help in an emergency. In other circumstances, my consent will be required. I give permission to exchange information with my child’s health care provider. I understand that I can limit or revoke this consent at any time. *
I understand that by typing my name following this question I am electronically signing this document as the parent/guardian of this student. *
Parent/Guardian Electronic Signature: *
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