School Registration

Emergency Contact 1
Name

First Name Last Name
Phone Number

Area Code Phone Number
Emergency Contact 2
Name

First Name Last Name
Phone Number

Area Code Phone Number
Physician and Medical Information
Name

First Name Last Name
Phone Number

Area Code Phone Number
Preferred Hospital
Insurance/Health Coverage (Company)
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.

Previous School 1
School Name
City
State
Date Started

Month Day Year
Date Ended

Month Day Year
Previous School 2
School Name
City
State
Date Started

Month Day Year
Date Ended

Month Day Year
Previous School 3
School Name
City
State
Date Started

Month Day Year
Date Ended

Month Day Year
Notes
Please inform the office of any other vital information you think they may need to know in the event of an emergency. Thank you.
Should be Empty:

Christ the King Preparatory Academy