Courtway Choir Medical/Personnel Form

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Please complete fully and accurately so that I may assist your child in an emergency situation. Do not leave blanks.

Student Last Name *

Student First Name *

Primary E-mail Address *

Student Date of Birth *

YYYY

Grade *

Street Address, City *

ZIP *

Student Cell Phone (None type N/A) *

Home Phone (None type N/A) *

Parent/Guardian 1 Name *

Parent/Guardian 1 Cell *

Parent/Guardian 1 Email (None type N/A) *

Parent/Guardian 1 Daytime Phone ( None type N/A) *

Parent/Guardian 2 Name *

Parent/Guardian 2 Email *

Parent/Guardian 2 Daytime Phone (None type N/A) *

Emergency Contact Excluding Parent *

Relationship *

Phone Number *

Medical History/Allergies (Check all that Apply) *

ADD/ADHD

Muscle Disorder

Cardiac Problems

Cerebral Palsy

Vision Problems

Lung Conditions

Kidney Problems

Asthma

Inhaler

Neurological Problems

Bowel Problems

Epi-Pen

High Blood Pressure

Other Medical

No Medical

Food Allergy

Environmental Allergy

Insect/Bee Sting Allergy

Medication Allergy

Other Allergy

No Allergy

Other:

Required

Explain Medical/Allergy Conditions (none type N/A) *

Has your child had... *

Chicken Pox

Chicken Pox/Varicella Vaccine

None

Does your child have health insurance? *

Yes

Insurance Carrier *

Medicaid AR/Kids *

Yes

Policy Number (none type N/A) *

Physicians Name *

Physicians Phone *

Dentist (none type N/A) *

Dentist Phone *

List prescription, over counter and herbal medication taken by your child (None type NA) *

DISTRICT POLICY: The Vilonia District policy regarding medication taken at school is in the Student Handbook. No medication will be given without a medical release signed by a parent or guardian from the School office. I, parent/guardian do hereby grant and give the Vilonia School District and/or its representative authorization and authority to treat and/or obtain emergency medical care for my child.The determination of whether an emergency exists or not, or whether medical care is needed or not, is left to the sole discretion of the school and/or its representative. Further, I do hereby authorize and grant to the school district and/or its representative authority to approve any necessary medical treatment that is determined by a physician or hospital emergency room staff to be needed for my child. The school will not be responsible for any incurred medical expenses. *

Yes

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