Grandview C-4 Summer Explorations2017
June 1–June 28, 2017
Contact Information/Health Form
(Grades K-12)
I. Student Information – (please print)Please use student’s legal name and current year school information.
Date______
First Name______
Middle Name ______
Last Name______
Ethnicity______
Gender (circle one) Male Female
Birth Date______
Student Address______
City______State_____Zip______
Current Grade Level (2016-2017) ______
Current School (2017-2017) ______
Parent/Guardian______
Home Phone______
Work Phone______
Cell Phone______
E-Mail Address______
Emergency Contact______
Emergency Phone______
Emergency Cell Phone______ / III. Health Information
Health problems or concerns: Yes_____ No_____
If yes, please describe:______
______
______
Is your child currently taking medication at school?
Yes _____ No _____
Name of Medication(s): ______
Is your child allergic to anything? Yes _____ No _____
If Yes, please identify: ______
______
Will your child need medication during Grandview C-4 Summer
Summer Explorations 2017? Yes* _____ No _____
Name of Medication:______
*If yes, child must have a medical form on site.
Name and Phone number of physician(s):
______
______
Hospital Preference: ______
In case of accident or serious illness, I request school personnel to contact me, emergency contact, or the named physician. If it is impossible to contact me, emergency contact, or the physician, the school personnel may make emergency arrangements as necessary to care for my child.
Yes _____ No _____
II. Transportation
Will your child be riding the bus? AM___ PM ___ Both___ No___
Transportation Address (if different from above):
______
After school: Ride bus ___ LINC ___
Other Transportation:
Walk____ Car____ Picked up by: ______
Daycare: ______
Other: ______ / IV. SPED (Special Education) Services
Please check if applicable:
_____My child receives SPED services and would like to attend Grandview C-4 Summer Explorations 2017 from June 1 – June 28, 2017.
V. Photo Release
I will allow any pictures taken of my child during participation in Grandview C-4 Summer Explorations 2017 to be used for Grandview C-4 advertising and promotional purposes.
Yes _____ No _____
Parent/Guardian Signature______Date______