Student Health Information Form

STUDENT HEALTH INFORMATION FORM
Student Information
Student Name*

First NameMiddle NameLast Name
Grade Entering*
School Year
Address*

Street Address

Apartment or Suite Number

CityState / Province

Postal / Zip Code
Home Phone Number
Date of Birth*

MonthDayYear
Date
Age
Student Lives With (Check all the apply)*

ParentsMotherFatherStep motherStep fatherJoint CustodyGuardianOther
Parent's Marital Status*

MarriedDivorcedSeparatedWidowSingleOther
Other Children in Family
Name
Age
Name
Age
Name
Age
Family Information For Primary Residence
Primary Parent
Relationship to the child
Email Address
example@example.com
Employer
Occupation
Home Phone Number
Cell Phone Number
Work Phone Number
Spouse
Relationship to the child
Email Address
example@example.com
Employer
Occupation
Home Phone Number
Cell Phone Number
Work Phone Number
Family Information For Secondary Residence
Primary Parent
Relationship to Child
Address

Street Address

Apartment or Suite Number

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Employer
Occupation
Home Phone Number
Cell Phone Number
Work Phone Number
Spouse
Relationship to the child
Email Address
example@example.com
Employer
Occupation
Home Phone Number
Cell Phone Number
Work Phone Number
Emergency Contacts Information
Two adults who will assume responsibility for your child if the parent/guardian cannot be reached.
Name
Relationship to Student
Phone Number 1
Phone Number 2
Name
Relationship to Student
Phone Number 1
Phone Number 2
Physician Information
Physician
Hospital
Health Information
Allergies (Food, drug, insect, other)
Medication (List ALL prescribed or taken on a regular basis)
Diagnosis of asthma?
Child wakes during the night coughing?
Birth Defects?
Developmental delay?
Blood disorders? Hemophilia, Sickle Cell, Other?
If Yes, Explain
Diabetes?
Head injury / Concussion / Passed out?
Seizures? What are they like?
Heart problems/ Shortness of breath?
Heart Murmur?
Dizziness or chest pain with exercise?
Loss of function of one of paired organs? (eye/ear/kidney/testicle)
Hospitalization?
If Yes, When? What for?
Surgery?
If Yes, (List all) When? What for?
Serious injury or illness?
TB Skin test positive? (past or present)
* If yes, refer to local health department
TB Disease? (past or present)
Tobacco use (type, frequency)?
Alcohol/Drug Use?
Family history of sudden death before age 50?
If Yes, Cause?
Eye /Vision problems?
Do you wear any of the below?

GlassesContacts
Last exam by eye doctor
Other concerns (lazy eye, crossed eye, drooping lids, squinting)
Ear / Hearing problems?
Bone / Joint problems / injury / scoliosis?
Dental

BracesBridgePlateOther
Please check the appropriate

Tylenol (Acetaminophen)Advil (Ibuprofen)Chewable Antacid
Please check the appropriate boxes pertaining to your student.

ADD/ADHDHeadachesStomachSpeech ProblemsNose BleedsAnxietyDiabetesNeurological
Parent Consent
- In consideration of Alpine Academy permitting my child to participate in all activities relating to school, I assume responsibility for my child’s participation and agree that Alpine Academy will not be held liable for any claims or demands of any nature whatsoever which may arise by or be in connection with my child. I further certify that I, the parent or guardian, consent to the performance of emergency treatment as deemed necessary by school personnel or physicians as a result of injury while participating in school activities. I understand that every attempt will be made to contact me prior to such treatment, but in the event that no contact is possible, I authorize the school to act on my behalf. I further agree that if the physician and hospital of my choice is not available in an emergency, the school has my permission to send my child to the nearest available hospital.
- In accordance with Alpine Academy of Rockford regulations on administering medications in the school, I authorize the nurse or designated person to provide for my child the medications listed below (or their generic equivalent), according to the appropriate dosage for my child’s age and weight or to administer epinephrine (Epi-pen) to any student experiencing a life threatening allergic reaction. I waive any claims I might have against the school, its employees, and agents arising out of the administration of said medication. In addition, I agree to release, hold harmless, and indemnify the School and its employees from any and all claims, damages, causes of action of injury incurred or resulting from the administration of attempts of said medication.
Parent Consent*

I hereby certify that the information on this application is accurate and complete, and I understand that incorrect information on any school form may result in non-acceptance or dismissal from Alpine Academy of Rockford. In addition:
Signature*

Clear
Alpine Academy of Rockford

5001 Forest View Avenue Rockford, IL 61108
815-227-8894

811 Locust St. Rockford illinois 61101
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STUDENT HEALTH INFORMATION FORM

Student Information

Other Children in Family

Family Information For Primary Residence

Family Information For Secondary Residence

Emergency Contacts Information

Physician Information

Health Information

Parent Consent