Current Health Information for Returning Students

Student Name *

Student Cell Phone

Graduation Year *

Please describe any new medical or emotional conditions 🛈

Current medications (Enter all of your child's medications, prescriptions and over-the-counter that is taken regularly)

NOTE: Please supply a physician's medical order for every regularly-taken medication.

Changes to telephone/cell number for each parent/legal guardian

Please * the best phone number to reach you.

You only need to list changes from last year.

Name

Relationship

Address

Address Line 2

City

State/Province

Zip/Postal Code

Country 🛈

Home Phone

Business Phone

Cell Phone

Fax

Other

Best number to reach 🛈

Name

Relationship

Address

Home Phone

Business Phone

Cell Phone

Fax

Other

Best number to reach 🛈

Please list any other changes to contact information.

Is your insurance information the same as last year? *

Yes

No

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