Online Registration - Medical Form

SYMMES JR. & D'ARCY McGEE HIGH SCHOOL

ONLINE REGISTRATION - MEDICAL FORM

Student Information:

Last Name:

First Name:

Grade Level:

Full Address:

Home Phone Number:

Program:

Student Lives With:

Mother's Information:

Last Name:

First Name:

Full Address:

Home Phone Number:

Father's Information:

Last Name:

First Name:

Full Address:

Home Phone Number:

Guardian's Information:

Last Name:

First Name:

Full Address:

Home Phone Number:

Work Phone Number:

Cell Phone Number:

E-Mail Address:

Emergency Contact Information (different from parent/guardian info):

1st Contact:

2nd Contact:

Daytime Phone Number:

Relationship to Student:

Transportation Arrangements Requested:

Note: Elegibility for transportation based on Western Quebec School Board transportation policy.

Emergency Medical Information:

Family Doctor's Name:

Phone Number:

Full Address:

Allergies:

Allergic to:

Asthma:

Other Medical Info:

Medical Card Number:

Expiration Date:

I give Symmes Jr./D'Arcy McGee High School permission to transport my child by ambulance to the hospital should they feel a medical emergency requires such action. I understand I will be responsible for all ambulance costs incurred.