Student Health Form
To complete this document you please grab your phone and insurance card.
Email *
Student Last Name *
Student First Name *
Student Date of Birth *
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Student Gender *
Student Address *
Zip Code *
Student Home Phone *
Father (Guardian) Name *
Father (Guardian) Work Number *
Father (Guardian) Cell Number *
Mother (Guardian) Name *
Mother (Guardian) Work Number *
Mother (Guardian) Cell Number *
Other Emergency Contact Name *
Relation to Student *
Cell/Primary Contact number for "Other Emergency Contact" *
Student's Physician *
Physician's Office Number *
Physician's Exchange or after hours number *
Name of Insurance Company *
Group Number *
Policy Number *
Date of last Tetanus shot *
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Does the student have any allergies, special health needs, or require medical care of any type. (Including current medication) *
If "Yes" please explain (If currently on medication, please list - When to take it, how much, and how often)
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. *
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. *
Today's Date *
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