Please enter Student First, Middle and Last Name and update the following information as needed:
Student ID Student First Name Student Middle Name Student Last Name Year of Graduation Gender Male Female Ethnicity Choose from the list White/Caucasian Hispanic/Latino Black/African American Asian American Indian/Alaskan Native Native Hawaiian/ Pacific Islander Date of Birth Birth City Birth State Birth Country For Transportation Purposes: Student Lives with For Transportation Purposes: In Which County? Primary Parent/Guardian (and Spouse) Name(s) Primary Parent/Guardian Physical Address Primary Parent/Guardian Mailing Address (if different) Primary Parent/Guardian Place of Employment Home Phone Work Phone Cell Phone Pager Number Email Address Spouse Place of Employment Home Phone Work Phone Cell Phone Pager Number E-mail Address Second Parent/Guardian Place of Employment Home Phone Work Phone Cell Phone Pager Number Email Address Spouse Place of Employment Home Phone Work Phone Cell Phone Pager Number E-mail Address Emergency Contact Name Emergency Contact Phone Number: Relationship to Student
Other Emergency Related Information:
Family Physician Physician Address Physician Phone Preferred Hospital Hospital Address Hospital Phone
My child has the following allergies: My child has the following condition which requires special handling: List serious illnesses, injuries, operations in the last year Are there any hearing difficulties? Does your child have tubes in his/her ears? Does your child wear glasses? Does your child wear contact lenses? When are the glasses to be worn? Are there any eye or visual difficulties? My child routinely takes the following medication(s): Were there any immunizations given in the last year that the Health Office was not informed of? Give exact dates.
