Name_________________________________________ Grade_____ Male ___ Female___  Birthdate ___________
            (Last)                                        (First)                    (M)
Student’s Address______________________________________ City________________ Phone______________

Parent(s)/Guardian(s) Name_________________________________________________ Phone______________

Address (If different than student’s)______________________________ City___________ Phone____________

Father’s/Guardian’s Employer____________________________ Phone____________ Beeper/Cell____________
Mother’s/Guardian’s Employer___________________________ Phone____________ Beeper/Cell____________
Step Parent/s Name________________________________________________ Phone______________________

In Case Parent/Guardian can not be reached, please contact:

Name:____________________________________ Relationship____________________ Phone______________

Physician’s Name________________________________________ Phone_____________________________
Dentist’s Name__________________________________________ Phone_____________________________
********************************************************************************************
Insurance Information
Insurance Company_______________________________________________ Phone_______________________
Address______________________________ City__________________________ State_______ Zip__________
Name of insured_________________________________________ Relationship to student__________________
Policy #____________________________________________ Group #_________________________________
Any other significant #’s_______________________________________________________________________

I hereby authorize school district employees or chaperones to call for emergency assistance which could require a doctor/dentist or emergency vehicle (ambulance).

Date_____________________ Signature of Parent/Guardian__________________________________________

Health Information
Any current/chronic health concerns that the school/teacher should be made aware of?_______________
_________________________________________________________________________________________
_________________________________________________________________________________________

Is the student currently taking medication(s) ________ Yes ________ No
Name of Medication(s)_______________________________________________________________________
Reason for Medication(s)_____________________________________________________________________
_________________________________________________________________________________________

Has the student ever had an allergic reaction? ________ Yes ________ No      If yes, what is the student allergic to? 

(Food, drug, animals, environment, bee/insect sting) ______________________________________
________________________________________________________________________________________
________________________________________________________________________________________

What type of reaction?______________________________________________________________________
________________________________________________________________________________________

If student requires medication at school or on a trip, it is the parent’s/guardian’s responsibility to provide the school with the medication ( an epi-pen if necessary) and a medication form signed by parent/guardian and physician.

I as parent/guardian give consent for this information to be shared with the appropriate staff or chaperones.

Date_______________________   Signature of Parent/Guardian__________________________________________