Please enter first and last name. Please designate person other than parent/guardian. Parents/guardians will always be notified first in event of an emergency.
Your answer
Relationship to Student *
Grandparent, Aunt, Neighbor, etc
Your answer
Best Phone Number to Use *
(xxx) xxx-xxxx
Your answer
Alternate Phone Number to Use
(xxx) xxx-xxxx
Your answer
Emergency Contact #2 *
Please enter first and last name. Please designate person other than parent/guardian. Parents/guardians will always be notified first in event of an emergency.
Your answer
Relationship to Student *
Grandparent, Aunt, Neighbor, etc
Your answer
Best Phone Number to Use *
(xxx) xxx-xxxx
Your answer
Alternate Phone Number to Use
(xxx) xxx-xxxx
Your answer
Medical Insurance Provider *
Your answer
Insurance Plan Title *
Type "unknown" if a title does not exist
Your answer
Insurance Group Number *
Enter "unknown" if group number does not exist
Your answer
Insurance Member ID Number
Your answer
Name of Family Physician *
Please include first and last name.
Your answer
Physician's Office Phone Number *
(xxx) xxx-xxxx
Your answer
Please list any known allergies:
Your answer
Please list any medications the student is currently taking:
Your answer
Special Medical Needs and/or Medication Needs
Please list any special medical concerns (ex. diabetes, seizures, etc.) and/or medications needs . Please also share any information that will allow us to more adequately care for your student.
Your answer
Medical Options *
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