Student Health And Emergency Information Form - Saint Joseph School - 2016-2017

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Teacher/Grade___________________
STUDENT HEALTH AND EMERGENCY INFORMATION FORM
SCHOOL YEAR 2016-2017
Please complete the following information and return to school health office as soon as possible. Contact the
school nurse if assistance is needed to complete form.
Student’s Name_____________________________________________________Date of Birth____________
Last
First
Middle
Home Address____________________________________________________________________________
Number
Street Name
APT #
City/Town
Home Phone______________________________Gender_____Primary Language_____________________
Mother/Guardian Name_____________________________________Relationship_____________________
Phone Number_____________________________________________________________________________
Home
Cell
Work
Father/Guardian Name______________________________________Relationship_____________________
Phone Number_____________________________________________________________________________
Home
Cell
Work
Family Members that attend St. Joseph
__________________________________________________________________________________________
Name
Grade
Please indicate two emergency contact names (other than parents) of friend/relative/neighbor who will assume
responsibility and provide transportation for your child in case of illness/injury/emergency evacuation:
Contact #1 Name____________________________________________Relationship____________________
Phone Number_____________________________________________________________________________
Home
Cell
Work
Contact #2 Name____________________________________________Relationship____________________
Phone Number_____________________________________________________________________________
Home
Cell
Work
Child’s Physician Name____________________________________Address__________________________
Phone Number______________________________Insurance Policy/Number_________________________
Child’s Dentist Name____________________________________Address__________________________
Phone Number______________________________Insurance Policy/Number_________________________
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