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 *
Your answer
Student Last Name *
Your answer
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.
Your answer
Relationship to Student *
Grandparent, Aunt, Neighbor, etc
Your answer
Best Phone Number to Use *
(xxx) xxx-xxxx
Your answer
Alternate Phone Number to Use
(xxx) xxx-xxxx
Your answer
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.
Your answer
Relationship to Student *
Grandparent, Aunt, Neighbor, etc
Your answer
Best Phone Number to Use *
(xxx) xxx-xxxx
Your answer
Alternate Phone Number to Use
(xxx) xxx-xxxx
Your answer
Medical Insurance Provider *
Your answer
Insurance Plan Title *
Type "unknown" if a title does not exist
Your answer
Insurance Group Number *
Enter "unknown" if group number does not exist
Your answer
Insurance Member ID Number
Your answer
Name of Family Physician *
Please include first and last name.
Your answer
Physician's Office Phone Number *
(xxx) xxx-xxxx
Your answer
Please list any known allergies:
Your answer
Please list any medications the student is currently taking:
Your answer
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.
Your answer
Medical Options *
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