Student Health Form
To complete this document you please grab your phone and insurance card.
* Required
Email address
*
Your email
Student Last Name
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Your answer
Student First Name
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Your answer
Student Date of Birth
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MM
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DD
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YYYY
Student Gender
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Choose
Female
Male
Student Address
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Your answer
Zip Code
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Your answer
Student Home Phone
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Your answer
Father (Guardian) Name
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Your answer
Father (Guardian) Work Number
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Your answer
Father (Guardian) Cell Number
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Your answer
Mother (Guardian) Name
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Your answer
Mother (Guardian) Work Number
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Your answer
Mother (Guardian) Cell Number
*
Your answer
Other Emergency Contact Name
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Your answer
Relation to Student
*
Choose
Grandparent
Aunt/Unlce
Neighbor
Other
Cell/Primary Contact number for "Other Emergency Contact"
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Your answer
Student's Physician
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Your answer
Physician's Office Number
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Your answer
Physician's Exchange or after hours number
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Your answer
Name of Insurance Company
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Your answer
Group Number
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Your answer
Policy Number
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Your answer
Date of last Tetanus shot
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MM
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DD
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YYYY
Does the student have any allergies, special health needs, or require medical care of any type. (Including current medication)
*
Choose
Yes
No
If "Yes" please explain (If currently on medication, please list - When to take it, how much, and how often)
Your answer
I/We understand and authorize in the event of an emergency or medical problem, a faculty member, school administrator, or the accompanying chaperone are empowered to make a decision regarding hospitalization and retention of a medical doctor.
*
Choose
Yes
No
I hereby authorize the emergency treatment, administration of anesthesia and surgical treatment of my minor child, in the event of an emergency medical situation occurring during my absence or when hospital/medical authorities are unable to contact me. I release from responsibility and liability hospital/medical authorities for performing medical procedures deemed necessary during my absence.
*
Choose
Yes
No
Today's Date
*
MM
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DD
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YYYY
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