Secondary Student Health Data Form
This form allows students at Pioneer Technology Center (PTC) to share health information and contact information which will only be used by staff members in the case of an emergency. An opportunity to opt out of medical treatment is also provided.
Sign in to Google to save your progress. Learn more
Email *
POLICY OF NON-DISCRIMINATION
Pioneer Technology Center does not discriminate on the basis of race, color, national origin, sex/gender, age, religion, disability, or veteran status. Inquiries concerning application of this policy should be made to Karl Lynes or Pam Dickerson, Co–Compliance Officers at (866) 612-4782 or at 2101 N. Ash, Ponca City, OK 74601
Student's First Name *
Student's Last Name *
Partner High School *
Student's Street Address
City/State
Zip Code
Parent/Guardian # 1 Name *
Parent/Guardian # 1 Primary Phone (Format: 580.762.8336) *
Parent/Guardian # 1 Other Phone (Format: 580.762.8336)
Parent/Guardian # 2 Name
Parent/Guardian # 2 Primary  (Format: 580.762.8336)
Parent/Guardian # 2 Other Phone  (Format: 580.762.8336)
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Pioneer Technology Center. Report Abuse
Google Forms