BLANCO INDEPENDENT SCHOOL DISTRICT
BLANCO INDEPENDENT SCHOOL DISTRICT 2017-2018 STUDENT HEALTH RECORD
kolton Student’s Name: __________________________________ (Last)
(First)
Grade: __________
(Middle)
Date of Birth: _______ - ________ - _________
Male
Female
With whom does the student live? Please list name and contact # of who should be contacted in case of illness or injury. PLEASE KEEP CONTACT NUMBERS UPDATED IN CASE OF EMERGENCY! 1. __________________________________________ _______________________________ (First & Last name)
(Relationship)
Cell phone # ____________________________________________ Email:_____________________________ Employer: _______________________________ Phone # __________________________________ 2. __________________________________________ _______________________________ (First & Last name)
(Relationship)
Cell phone # ____________________________________________ Email:_____________________________ Employer: _______________________________ Phone # __________________________________ If you cannot be reached we will call the following people in this order: Name: __________________________________ Daytime phone # ______________________ Name: ___________________________________Daytime phone # _______________________ Name: ___________________________________Daytime phone # _______________________ Please list any medical conditions we should be aware of: ___________________________ Please list any food, drug or insect allergies: _____________________________________ MEDICINE must be provided by the PARENTS in the ORIGINAL CONTAINER. We must have WRITTEN permission from your DOCTOR for ALL MEDICINES given at school. • This document gives school personnel written consent to seek emergency treatment for your child and to communicate with your health care professional regarding conditions, treatments and medicines. Doctor’s Name: __________________________________
Phone #: ____________________
Signature of Parent/Guardian: _____________________________________ Date: __________________________________
BLANCO INDEPENDENT SCHOOL DISTRICT 2017 – 2018 TRAVEL PERMISSION SLIP
I hereby give consent for my son/daughter to travel with the coach/sponsor/representative of any school-sponsored field trip or University Interscholastic League event. This will serve as permission for any School-sponsored trip for the 2017-2018 school year. In the event of illness or accident, the district’s representatives may obtain any Medical assistance they deem necessary. Furthermore, in case of an emergency, I give the district’s representatives permission to act on my behalf to ensure the safety of my child.
Parent’s/Guardian’s Signature
Emergency Telephone Number(s) Allergies or Medication:
Date
kolton Student’s Name: __________________________________ (Last)
(First)
Grade: __________
(Middle)
Date of Birth: _______ - ________ - _________
Male
Female
With whom does the student live? Please list name and contact # of who should be contacted in case of illness or injury. PLEASE KEEP CONTACT NUMBERS UPDATED IN CASE OF EMERGENCY! 1. __________________________________________ _______________________________ (First & Last name)
(Relationship)
Cell phone # ____________________________________________ Email:_____________________________ Employer: _______________________________ Phone # __________________________________ 2. __________________________________________ _______________________________ (First & Last name)
(Relationship)
Cell phone # ____________________________________________ Email:_____________________________ Employer: _______________________________ Phone # __________________________________ If you cannot be reached we will call the following people in this order: Name: __________________________________ Daytime phone # ______________________ Name: ___________________________________Daytime phone # _______________________ Name: ___________________________________Daytime phone # _______________________ Please list any medical conditions we should be aware of: ___________________________ Please list any food, drug or insect allergies: _____________________________________ MEDICINE must be provided by the PARENTS in the ORIGINAL CONTAINER. We must have WRITTEN permission from your DOCTOR for ALL MEDICINES given at school. • This document gives school personnel written consent to seek emergency treatment for your child and to communicate with your health care professional regarding conditions, treatments and medicines. Doctor’s Name: __________________________________
Phone #: ____________________
Signature of Parent/Guardian: _____________________________________ Date: __________________________________
BLANCO INDEPENDENT SCHOOL DISTRICT 2017 – 2018 TRAVEL PERMISSION SLIP
I hereby give consent for my son/daughter to travel with the coach/sponsor/representative of any school-sponsored field trip or University Interscholastic League event. This will serve as permission for any School-sponsored trip for the 2017-2018 school year. In the event of illness or accident, the district’s representatives may obtain any Medical assistance they deem necessary. Furthermore, in case of an emergency, I give the district’s representatives permission to act on my behalf to ensure the safety of my child.
Parent’s/Guardian’s Signature
Emergency Telephone Number(s) Allergies or Medication:
Date
