Health Form
By filling and signing this form, and in the event of an emergency, you give permission for your child to be treated as deemed necessary and given access to emergency personnel. You are giving this information to assist medical personnel and chaperones in their care of your child in accordance with privacy regulation.
Student Name *
Your answer
Grade (Fall of 2017) *
Date of Birth *
Your answer
Home Address *
Your answer
Parent Email Address
Your answer
Student Email Address
Your answer
Parent #1 Name *
Your answer
Parent #1 Address *
Your answer
Parent #1 Place of Employment *
Your answer
Parent #1 Work Phone *
Your answer
Parent #1 Home Phone *
Your answer
Parent #1 Cell Phone *
Your answer
Parent #1 Email Address *
Your answer
Parent #2 Name
Your answer
Parent #2 Address
Your answer
Parent #2 Work Phone
Your answer
Parent #2 Home Phone
Your answer
Parent #2 Cell Phone
Your answer
Parent #2 Email Address
Your answer
EMERGENCY CONTACT NAME (If Parent #1 and #2 are unable to be reached) *
Your answer
Relationship to Child: *
Your answer
Address:
Your answer
Home Phone *
Your answer
Work Phone *
Your answer
Cell Phone *
Your answer
In the event of an emergency, I give permission for my child to be treated as deemed necessary and given access to ermgency personnel and chaperones my child's medical information to assist in their care in accordance with privacy regulations. *
(Typing name constitutes an electronic signature)
Your answer
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