2024-2025 Student Health Information Form

Please complete the form below. Required fields marked with an asterisk *

Student First Name*

Answer Required

Student Last Name*

Answer Required

DOB*

Answer Required

Street Address*

Answer Required

City*

Answer Required

State*

Answer Required

Zip/Postal*

Answer Required

Parent/Guardian First Name (1)*

Answer Required

Parent/Guardian Last Name (1)*

Answer Required

Relationship to student*

Answer Required

Phone # (Best during school day)*

Number Required

Mobile Phone

Number Required

Parent/Guardian First Name (2)*

Answer Required

Parent/Guardian Last Name*

Answer Required

Relationship to student*

Answer Required

Phone # (Best during school day)*

Number Required

Mobile Phone

Number Required

Emergency Contact - Full Name #1*

Answer Required

Relationship to student*

Answer Required

Phone #*

Number Required

Emergency Contact - Full Name #2*

Answer Required

Relationship to student*

Answer Required

Phone #*

Number Required

Physician Name*

Answer Required

Phone #*

Number Required

Preferred Hospital*

Answer Required

Student Health Insurance*

Answer Required

Group #*

Answer Required

Policy #*

Answer Required

Effective Date*

Answer Required

If you checked Allergy, Special Needs, or Mental Health boxes above, please explain further as it pertains to your selection:

Answer Required

Are you allergic to any medications?*

Answer Required

Yes

If you selected yes above, please explain which medications.

Answer Required

I hereby give consent/release for emergency medical treatment as necessary.

I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By signing using any device, means, or action, I consent to the legally binding terms and conditions of this document. I further agree that my signature on this document is as valid as if I signed the document in writing. I am also confirming that I am authorized to enter into this Agreement. If I am signing this document on behalf of a minor, I represent and warrant that I am the minor’s parent or legal guardian.

Signature*

Signature Required

Please fix the highlighted areas below before submitting.

2024-2025 Student Health Information Form