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  • Student Health Registration

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    Kelley Johnson
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    This student health registration form collects contact and medical information for a student. It requests the student's name, SSN, address, date of birth, emergency contact name and contact information, and descriptions of any recent or chronic illnesses, allergies, medications, or other medical restrictions. The parent or guardian must provide consent for emergency medical treatment by signing and dating the form along with providing their home, cell, and work phone numbers.

    Original Description:

    Health form for Summer Band Camp

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    This student health registration form collects contact and medical information for a student. It requests the student's name, SSN, address, date of birth, emergency contact name and contact information, and descriptions of any recent or chronic illnesses, allergies, medications, or other medical restrictions. The parent or guardian must provide consent for emergency medical treatment by signing and dating the form along with providing their home, cell, and work phone numbers.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    9 views1 page

    Student Health Registration

    Uploaded by

    Kelley Johnson
    This student health registration form collects contact and medical information for a student. It requests the student's name, SSN, address, date of birth, emergency contact name and contact information, and descriptions of any recent or chronic illnesses, allergies, medications, or other medical restrictions. The parent or guardian must provide consent for emergency medical treatment by signing and dating the form along with providing their home, cell, and work phone numbers.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    of 1

    STUDENT HEALTH REGISTRATION

    Student Name _________________________________SSN# _____________________


    Address_________________________________________________________________
    Date of Birth_____________________________________________________________
    Contact Person Name_________________________ Contact Person #_______________
    Contact Person Address____________________________________________________
    Contact Person Relationship_________________________________________________
    Describe the Following: (use back if necessary)
    Recent illness (es) ________________________________________________________
    _______________________________________________________________________
    Chronic or long-term illness (es) _____________________________________________
    _______________________________________________________________________
    Allergies ________________________________________________________________
    ________________________________________________________________________
    Medicines currently being taken _____________________________________________
    _______________________________________________________________________
    Other medical or physical restrictions _________________________________________
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________
    ________________________________________________________________________

    Parent or Guardian Consent Statement


    I grant permission for the above named person to be treated and/or hospitalized by a licensed
    physician if an emergency situation arises.
    SIGNED: ______________________________________________DATE:___________
    HOME PHONE: _______________________CELL PHONE: _____________________
    WORK PHONE: _______________________

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