Summer School Registration 2019

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Student First Name: *

Student Last Name: *

Home Phone Number *

Student's Birthday *

YYYY

School the student will attend in 2019-20 *

Grade level the student is CURRENTLY in *

Home Street Address *

City *

Zip Code *

Email Address *

Select Course *

90123 SUMMER BAND JUMP START, Gr. 4, 8-12:00, Theisen

90120 SUMMER BEGINNING ORCHESTRA, Gr. 4, 9:30-11:00 Theisen

90121 INTRO TO MIDDLE SCHOOL ORCHESTRA, Gr. 5, 11-12:00 Theisen

Other:

Select Course (Second Choice if taking more than 1 class)

90123 SUMMER BAND JUMP START, Gr. 4, 8-12:00, Theisen

90120 SUMMER BEGINNING ORCHESTRA, Gr. 4, 9:30-11:00 Theisen

90121 INTRO TO MIDDLE SCHOOL ORCHESTRA, Gr. 5, 11-12:00 Theisen

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Emergency Contact Information

Father/Guardian's Name

Please list first and last name.

Father/Guardian's contact phone number

xxx-xxx-xxxx

Father/Guardian's work phone number

xxx-xxx-xxxx

Mother/Guardian's Name

Please list first and last name

Mother/Guardian's contact phone number

xxx-xxx-xxxx

Mother/Guardian's work phone number

xxx-xxx-xxxx

Emergency Contact Person *

Emergency Contact's phone number *

xxx-xxx-xxxx

Emergency Contact Person (second person) *

Emergency Contact's phone number (second person)

xxx-xxx-xxxx

Health Information

I/we are aware the information provided and authorize the release of this information to appropriate school personnel.

Will your child require prescription medication during the hours they are attending summer school? *

Yes

If yes, please list any medications:

If yes, a Physician's Order for Administration of Medication form will need to be completed. Forms are available in your child's school office or at the following link:

www.fonddulac.k12.wi.us/uploads/Physician_order_for_medication.doc

Please call School Health Programs with questions, 906-6548.

Physician's Name *

Physician's phone number *

xxx-xxx-xxxx

Dentist's name *

Dentist's phone number *

xxx-xxx-xxxx

List significant health problems or disabilities and appropriate action (e.g. asthma, bee sting allergy, seizures, etc.)

Have you worked with a school nurse to develop a health care plan/emergency plan for this condition?

Yes

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Procedures

Procedures followed in case of illness or injury:

1. Contact Parent/Guardian
2. Contact designated Emergency contact person
3. If unable to reach above individuals and situation warrants, call ambulance/physician
4. If severe illness or injury, call ambulance.

The information provided here is confidential information. Not for Distribution.

By checking this box, I agree that all the medical information I have provided is correct.

Required

Submit

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