Student Enrollment Form (Page 2 of 2) in pdf

Student Legal Name: __________________________________________________________________________________

First

Last

(MI)

In case of emergency regarding this student, we will always call the numbers associated with the adults in the

student’s home. If we cannot reach one of the listed adults, what other family or friends may be of help?

Emergency Contact 1: ________________________________ Primary Phone: ___________________________

Relationship:

_______________________________

Emergency Contact 2: ________________________________ Primary Phone: ___________________________

Relationship:

_______________________________

Emergency Contact 3: ________________________________ Primary Phone: ___________________________

Relationship:

_______________________________

DIRECTORY INFORMATION

Directory information about a student is routinely available to the public. For an explanation on what directory

information includes and the process to opt out of the release of student directory information, please refer to the

Parent-Student Handbook.

STUDENT HEALTH INFORMATION

Please provide specific information for your child. Information will be held in confidence.

Health Conditions (asthma, diabetes, vision/hearing problems, immune deficiency, seizures, cancer, heart disease)

______________________________________________________________________________________________________

Allergies

______________________________________________________________________________________________________

Injury/illness/surgery (e.g., broken bones, chicken pox, hepatitis, appendectomy)

______________________________________________________________________________________________________

Medication taken regularly (please give name of medicine/dosage/reason needed)

______________________________________________________________________________________________________

Date and results of any of the following exams within the last 12 months:

Physical _______________________

Dental _______________________

Eye _______________________

I understand and agree this information will be reviewed by the school nurse and shared with school staff when appropriate.

Signature of Parent/Guardian __________________________________________________ Date ___________

Student Enrollment Form Page 2