Student Health Form
To complete this document you please grab your phone and insurance card.
Email address *
Student Last Name *
Your answer
Student First Name *
Your answer
Student Date of Birth *
MM
/
DD
/
YYYY
Student Gender *
Student Address *
Your answer
Zip Code *
Your answer
Student Home Phone *
Your answer
Father (Guardian) Name *
Your answer
Father (Guardian) Work Number *
Your answer
Father (Guardian) Cell Number *
Your answer
Mother (Guardian) Name *
Your answer
Mother (Guardian) Work Number *
Your answer
Mother (Guardian) Cell Number *
Your answer
Other Emergency Contact Name *
Your answer
Relation to Student *
Cell/Primary Contact number for "Other Emergency Contact" *
Your answer
Student's Physician *
Your answer
Physician's Office Number *
Your answer
Physician's Exchange or after hours number *
Your answer
Name of Insurance Company *
Your answer
Group Number *
Your answer
Policy Number *
Your answer
Date of last Tetanus shot *
MM
/
DD
/
YYYY
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)
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. *
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 *
MM
/
DD
/
YYYY
Next
Never submit passwords through Google Forms.
This form was created inside of Mehlville School District. Report Abuse