Please PRINT or TYPE the following information – Thank You
Student Name:
________________________________________DOB:__________
Parent/Guardian:
________________________________________
Home Address (no PO Box,
Please!)_______________________________________________
Home Phone#: _______________ Cell
Phone# : _______________ Work Phone # _________
IN
CASE OF EMERGENCY- - PLEASE NOTIFY (Other than parents)
Name:
___________________________________________Relationship__________________
Home Address: ___________________________
Home Phone #_______________ Cell Phone#:
_______________Work Phone#_____________
Health
History
Family
Physician:_____________________________________________Tel # ___________
Are
there any illnesses or conditions for
which this child is currently receiving treatment we need to be aware of?
Yes____ No_____
Please describe
Does you child have any allergies to
food, medication, bees? Yes_____ No______
Reaction to
what?________________________________________
Type of reaction and
severity?______________________________
Does your child carry an
Epi-Pen? Yes____ No______
Date of last Tetanus
Immunization: ________________________________
_________________________________________________________________________________
In case of a medical emergency, I hereby authorize any
licensed physician, hospital, clinic or other medical facility to hospitalize
and secure treatment for my child as named above.
Heath Insurance Co:
__________________________________Policy No: ____________________
Signature of Parent/Guardian___________________________________________________
DATE: _______________________
NO STUDENT WILL BE ALLOWED TO
PARTICIPATE WITHOUT THIS FORM PROPERLY COMPLETED AND RETURNED.
PLEASE
FILL OUT BACK
OF THIS SHEET .
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