Medical Information - Campus Programs

Medical Information - Campus Programs

Please submit this secure, HIPAA-compliant form within two weeks of registering. It provides staff with contacts and other important health-related information that can be used proactively and also in case of an emergency. Thank you!
Academic Year*

2025-262026-272027-282028-292029-30
Parent / Guardian First Name*
Parent / Guardian Last Name*
Student information
First Name - Student #1 *
Last Name - Student #1 *
Birth Date MM/DD/YYYY - Student #1 *
Health notes - Student #1*
First Name - Student #2
Last Name - Student #2
Birth Date MM/DD/YYYY - Student #2
Health notes - Student #2
First Name - Student #3
Last Name - Student #3
Birth Date MM/DD/YYYY - Student #3
Health notes - Student #3
First Name - Student #4
Last Name - Student #4
Birth Date MM/DD/YYYY - Student #4
Health notes - Student #4
First Name - Student #5
Last Name - Student #5
Birth Date MM/DD/YYYY - Student #5
Health notes - Student #5

Healthcare information
Pediatric Practice
(e.g., Annandale Pediatrics)
Pediatrician Name
e.g., John Doe, MD
Pediatrician Phone

Area CodePhone Number
Do you have medical insurance / healthcare sharing plan?*

Yes - Medical InsuranceYes - Healthcare sharing planNo insurance or healthcare sharing plan
Insurance Provider or Healthcare Sharing Plan:
e.g., Aetna, Medishare
Policy Holder / Subscriber First Name
Policy Holder / Subscriber Last Name
ID #:
ID # from your insurance card
Insurance / Healthcare Plan Phone

Area CodePhone Number

Consent and Authorization

Required for enrollment.
This authorization complies with Virginia Code § 32.1-127 and EMS regulations. It remains valid for the duration of the homeschool program year unless revoked in writing. I, the undersigned parent/legal guardian of the above-named child/children, hereby authorize any adult designated by the homeschool program to: * Seek emergency medical care for my child when I cannot be reached. * Consent to evaluation, treatment, and procedures deemed necessary by licensed medical personnel. * Administer or authorize administration of an EpiPen or other prescribed emergency medication.* Transport my child to a hospital or urgent care facility if needed. * Share relevant medical information with emergency responders and healthcare providers.By typing my full name below, I affirm that I am the legal parent or guardian of the child named in this form. I understand that this typed name constitutes my electronic signature and carries the same legal effect as a handwritten signature under the Electronic Signatures in Global and National Commerce Act (E-SIGN) and Virginia’s Uniform Electronic Transactions Act (UETA). I authorize the homeschool program and its designated representatives to act in accordance with the permissions outlined above.
Name of authorizer*

First NameLast Name
Today's Date*

MonthDayYear
Date
Comments
Comments

Any additional comments, up to 300-character limit.0/300
Should be Empty:

Student information