Application For Entrance And Emergency Medical Form printable pdf download

Application for Entrance and Emergency Medical Form

For Office use only

Student #__________________ School_________________________________________________

Grade_____________________

Teacher/HR _________________________________________ Bus No.___________

Student Information

Last Name __________________________ First_______________ Middle_______________ Sex___ Race

(see back of form)

Social Security Number_______________________________ Birth Date______________ Home Phone__________________

Birth Certificate Number__________________ City, State, Country of Birth _______________________________________

Grade at Last School Attended_____ Last School Attended_____________________________________________________

Address___________________________________________ Has student ever attended Lynchburg City Schools? _Yes _No

If yes, which school?_____________________________________________________ Year_________ Grade____________

Name of Pre-School(s) Attended __________________________________________________________________________

How many days per week did child attend preschool? ________

Child attended for __Full Day

__ Half Day

Is this child currently residing in a foster home? __Yes __No

Has this child ever been found guilty or delinquent in a court of law? __Yes __No

) Please describe__

(Per Code of VA § 22.1-3.2

______________________________________________________________________________________________________

Parents/guardians with whom the child lives (person/s who have primary physical custody of child)

Parent/Guardian Name__________________________________________________ Relationship___________________

Residence Address_______________________________________________________________________ZIP____________

Home Phone____________ Unlisted? __ Employer___________________________________ Work Phone_____________

E-Mail Address_______________________________________________ Cell Phone_____________

Parent/Guardian Name__________________________________________________ Relationship___________________

Employer______________________________________________________________________ Work Phone ____________

E-Mail Address_______________________________________________ Cell Phone_____________

Primary language spoken in the home _English _Spanish _French _Other (please specify)__________________________

Parents/guardians with whom the child DOES NOT live (for example, father and stepmother)

Parent/Guardian Name___________________________________________________ Relationship___________________

Use this person as a contact in case of emergency? __Yes

__No

Address_________________________________________________ZIP____________ Home Phone____________________

Employer______________________________________________________________ Work Phone_____________________

E-Mail Address_______________________________________________ Cell Phone_____________ Pager_____________

Parent/Guardian Name___________________________________________________ Relationship___________________

Use this person as a contact in case of emergency? __Yes

__ No

Address _________________________________________________ZIP____________ Home Phone____________________

Employer______________________________________________________________ Work Phone ____________________

Additional Emergency Contacts

In the event that there is an emergency and the parents/guardians above can’t be reached, whom should we contact?

1. Name__________________________________________ Phone_____________ Relationship______________________

Cell Phone_________________________________

2. Name__________________________________________ Phone_____________ Relationship______________________

Cell Phone_________________________________

Medical Information

Physician’s Name______________________________________________________________ Phone___________________

List all allergies, including drug and food allergies ____________________________________________________________

______________________________________________________________________________________________________

List any serious chronic medical condition the child may have, such as heart problems, asthma, diabetes, seizures, etc. ______

______________________________________________________________________________________________________

List all medications the child is currently taking on a regular basis_________________________________________________

______________________________________________________________________________________________________

Medical Release

I realize that I, as the Parent/Guardian, am responsible for notifying the school of any changes of the above information including change of address, new phone number,

medical problems, etc. I hereby authorize the school and/or hospital to provide medical care for my child according to their best judgment, and agree to pay expenses so incurred,

including ambulance transportation if necessary.

_______________________

____________________________________________________

Parent/Guardian’s Signature

Date

EmergencyMedicalForm Rev. 12 07/25/2012 J. McKinney