2020-2021 Hinton Community School Student Registration

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Email *

Student Legal Last Name *

Student Legal First Name *

Student Legal Middle Name *

Preferred name if different from legal name

Date of Birth *

YYYY

Gender *

Female

Male

Social Security Number

Grade in 2020-2021 *

Student's Cell Phone Number

Student Lives with *

Both Parents

Mother

Father

Legal Guardian

Parent & Step Parent

Other:

Required

Who is the responsible Parent/Guardian? *

Please list name and relationship to the child.

Does your child have permission to have their picture posted on school social media such as Twitter and Facebook? *

Yes

In the event your child is ill, whom should be contacted that can pick up your child within 30 minutes. Please list names, phone numbers and relationships to child. *

Physicians Name *

Physicians Phone Number

Dentist Name *

Dentist Phone Number

Hospital Choice: *

Unity Point

MercyOne

Floyd Valley

Orange City

Other:

Please list any allergies: *

Please list all medications: *

Does your child have any special medical considerations: *

In the case of an emergency, if necessary, take student to the nearest medical facility. *

Yes

I give permission to share health information with the appropriate staff. *

Yes

Nurse/Medication

All prescriptions brought to school must be in a container appropriately labeled by the pharmacist or physician. All over the counter medicine must come in its original container.
A medication authorization form needs to be signed by a physician and the parent or guardian for any prescription or over the counter medication given longer than two weeks.
Students with asthma are REQUIRE the medication authorization form to be completed, including students who are self administering asthmas medications.

Permission to administer medication *

I give permission for the health office to administer Tylenol/Acetaminophen or Ibuprofen under the discretion of the nursing staff. The nurse will give these only if the assessment warrants it. Hinton Community School has the right to DENY these medications.

I DO NOT give permission for the health office to administer Tylenol/Acetaminophen or Ibuprofen under the discretion of the nursing staff.

Medical - Asthma *

My child has asthma

My child DOES NOT have asthma

Note to parents:

Please call or email the nurse if you have information to share regarding your child's health.

Will your student need transportation to and from school for the 2020-2021 School year? *

Yes

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