Blue Data Collection Form Student (Page 2 of 2) in pdf

LAST NAME

FIRST NAME

OSIS

RETURN THIS FORM TO ROOM 029

# HEALTH INFORMATION

Name of Physician/Clinic: __________________________________________________________________________________ Tel # (

)_______________________________

HEALTH ALERT

Does your child have any health condition that may affect participation in physical activities? Yes____ No____

Limitations ____________________________________________________________________________________________________________________(e.g. stair climbing, participation in gym, etc.)

Allergies _________________________________________________________________________________________________________________________________________________________________

504 services for the current year? Yes___ No___

Previous year? Yes___ No___

My Child has (X any that apply) Private health insurance _______ Medicaid ______ No health insurance _______

If “No Health Insurance” are you willing to share contact information from this card to learn about insurance options? Yes____ No___

If none of the named contacts can be reached, what do you wish the school to do if your child is sick or injured? _____________________________________________________________________________

It is understood that in the final disposition of an emergency case, the judgment of school authorities will prevail. The recommendation of the parent as indicated above will be respected as far as possible.

DATA PERMISSIONS

Description of Permission Given

I give permission to allow my child to design and publish web pages on the Department of Education Facilities, World Wide Web and/or the Bronx H.S. of Science’s website.

I want to receive attendance, lateness, grade and school events information by e-mail.

I give permission for a photographic or video image of my child, an audio recording, poetry, art work or other work produced in conjunction with awards, athletic activities or other school

activities, to be published, broadcast or placed on the Department of Education and the Bronx High School of Science’s website, or used for publicity, for news, or promotion of the Bronx High

School of Science.

I give permission to the Bronx High School of Science to give my names, addresses, phone number and e-mail address to the Parents’ Association of the Bronx High School of Science solely for

the purpose of allowing me to receive communications from the Parents’ Association.

I give permission to the Bronx High School of Science to give my telephone number to my child’s Big Sib so that his/her Big Sib can contact my child.

In the event of an emergency, I would like to receive messages by text messaging (if possible.)

To my knowledge the information provided on this form is true and valid. I have read and will follow the rules, regulations and the Computer and Internet Acceptable Usage policy of

the Department of Education and of the Bronx High School of Science.

Student Signature ______________________________________________________________________

Parent/Guardian #1 Signature ____________________________________________________________________

Parent/Guardian #2 Signature ___________________________________________________________________