Charger Pride Forms 2019-2020
Please be prepared to spend a few minutes to complete these forms. You will need access to your student's medical information, including doctor information, insurance information, etc. We appreciate your prompt attention to this form.
Student First Name *
Student Last Name *
Emergency Contact #1 *
Please enter first and last name. Please designate person other than parent/guardian. Parents/guardians will always be notified first in event of an emergency.
Relationship to Student *
Grandparent, Aunt, Neighbor, etc
Best Phone Number to Use *
(xxx) xxx-xxxx
Alternate Phone Number to Use
(xxx) xxx-xxxx
Emergency Contact #2 *
Please enter first and last name. Please designate person other than parent/guardian. Parents/guardians will always be notified first in event of an emergency.
Relationship to Student *
Grandparent, Aunt, Neighbor, etc
Best Phone Number to Use *
(xxx) xxx-xxxx
Alternate Phone Number to Use
(xxx) xxx-xxxx
Medical Insurance Provider *
Insurance Plan Title *
Type "unknown" if a title does not exist
Insurance Group Number *
Enter "unknown" if group number does not exist
Insurance Member ID Number
Name of Family Physician *
Please include first and last name.
Physician's Office Phone Number *
(xxx) xxx-xxxx
Please list any known allergies:
Please list any medications the student is currently taking:
Special Medical Needs and/or Medication Needs
Please list any special medical concerns (ex. diabetes, seizures, etc.) and/or medications needs . Please also share any information that will allow us to more adequately care for your student.
Medical Options *
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