Vilonia Choir Medical/Personnel Form
Please complete fully and accurately so that I may assist your child in an emergency situation. Do not leave blanks.
E-mail Address *
Your answer
Last Name *
Your answer
First Name *
Your answer
Date of Birth *
MM
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DD
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YYYY
Grade *
Street Address, City *
Your answer
ZIP *
Your answer
Student Cell Phone (None type N/A) *
Your answer
Home Phone (None type N/A) *
Your answer
Parent/Guardian 1 Name *
Your answer
Parent/Guardian 1 Cell *
Your answer
Parent/Guardian 1 Email (None type N/A) *
Your answer
Parent/Guardian 1 Daytime Phone ( None type N/A) *
Your answer
Parent/Guardian 2 Name *
Your answer
Parent/Guardian 2 Email *
Your answer
Parent/Guardian 2 Daytime Phone (None type N/A) *
Your answer
Emergency Contact Excluding Parent *
Your answer
Relationship *
Your answer
Phone Number *
Your answer
Medical History/Allergies (Check all that Apply) *
Required
Explain Medical/Allergy Conditions (none type N/A) *
Your answer
Has your child had... *
Does your child have health insurance? *
Insurance Carrier *
Your answer
Medicaid AR/Kids *
Policy Number (none type N/A) *
Your answer
Physicians Name *
Your answer
Physicians Phone *
Your answer
Dentist (none type N/A) *
Your answer
Dentist Phone *
Your answer
List prescription, over counter and herbal medication taken by your child (None type NA) *
Your answer
DISTRICT POLICY: The Vilonia District policy regarding medication taken at school is in the Student Handbook. No medication will be given without a medical release signed by a parent or guardian from the School office. I, parent/guardian do hereby grant and give the Vilonia School District and/or its representative authorization and authority to treat and/or obtain emergency medical care for my child.The determination of whether an emergency exists or not, or whether medical care is needed or not, is left to the sole discretion of the school and/or its representative. Further, I do hereby authorize and grant to the school district and/or its representative authority to approve any necessary medical treatment that is determined by a physician or hospital emergency room staff to be needed for my child. The school will not be responsible for any incurred medical expenses. *
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