Ashe Preparatory K-5: New Student Registration Form

C. MEDICAL AND EMERGENCY INFORMATION

The following information is important in case of an accident, illness, or other emergency when the parent/guardian cannot be located. The following persons have agreed to accept full responsibility in case of an emergency or urgency and are authorized to assume responsibility and make decisions.
Emergency Contact #1

First NameLast Name
Relationship to child:
Phone:
Please enter a valid phone number.
School Pick-up

YesNo
Emergency Contact #2

First NameLast Name
Relationship to child:
Phone:
Please enter a valid phone number.
School Pick-up

YesNo
Emergency Contact #3

First NameLast Name
Relationship to child:
Phone:
Please enter a valid phone number.
School Pick-up

YesNo
IN CASE OF EMERGENCY:

If paramedics and/or hospital personnel might be involved, my child’s medical identification is below. I hereby authorize emergency medical attention by any licensed physician or my doctor, listed below, if it becomes necessary. I agree to pay for reasonable professional services or hospitalization, including an ambulance, if used
Health Care Provider or Medical Insurance:
Member or Card #:
Doctor’s Name:
Telephone:
Please enter a valid phone number.
Does the student have any chronic health problems, medical conditions, medications, or allergies that Ashé Prep should know about? If so,please specify below.*

E. PARENT/GUARDIAN SIGNATURE:
I ATTEST, UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON, THAT THE INFORMATION SUBMITTED IN AND WITH
THIS STUDENT ENROLLMENT FORM IS TRUE AND CORRECT.
Signature*

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Please check 'yes' if the parent/legal guardian(s) does not wish to be contacted by Ashé Preparatory Academy regarding public issues thatcould impact your child.

Yes
Should be Empty:

A. STUDENT INFORMATION