Charger Pride Forms 2020-2021
Please be prepared to spend a few minutes to complete these forms. You will need access to your student's medical information, including doctor information, insurance information, etc. We appreciate your prompt attention to this form.
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Student First Name *
Student Last Name *
Emergency Contact #1 *
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.
Relationship to Student *
Grandparent, Aunt, Neighbor, etc
Best Phone Number to Use *
(xxx) xxx-xxxx
Alternate Phone Number to Use
(xxx) xxx-xxxx
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.
Relationship to Student *
Grandparent, Aunt, Neighbor, etc
Best Phone Number to Use *
(xxx) xxx-xxxx
Alternate Phone Number to Use
(xxx) xxx-xxxx
Medical Insurance Provider *
Insurance Plan Title *
Type "unknown" if a title does not exist
Insurance Group Number *
Enter "unknown" if group number does not exist
Insurance Member ID Number
Name of Family Physician *
Please include first and last name.
Physician's Office Phone Number *
(xxx) xxx-xxxx
Please list any known allergies:
Please list any medications the student is currently taking:
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.
Medical Options *
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