Student Medical History

Student Information

Student First Name*

Answer Required

Student Last Name*

Answer Required

Student Date of Birth*

Answer Required

Sex*

Answer Required

Current Grade*

Answer Required

Street Address*

Answer Required

City*

Answer Required

Zip/Postal*

Answer Required

Mother's Information

Name

Answer Required

Phone

Number Required

Work or Cell

Number Required

Father's Information

Name

Answer Required

Phone

Number Required

Work / Cell

Number Required

Guardian's Information (If not parent)

Name

Answer Required

Phone

Number Required

Work / Cell

Number Required

Primary Care Information

Doctor's Name

Answer Required

Doctor's Phone

Number Required

Dentist's Name

Answer Required

Dentist's Phone

Answer Required

Type of Health Insurance

Answer Required

HMO

Medicaid

No Health Insurance

Other

If the student is covered by Medicaid, provide the Medicaid number:

Answer Required

EMERGENCY RELEASE: Premier Arts Academy will attempt to reach the parent/legal guardian or one of the people listed as an emergency contact, but if none of these people can be reached, Premier Arts Academy personnel have my permission to use discretion in securing medical aid in an emergency. IT IS UNDERSTOOD THAT NEITHER PREMIER ARTS ACADEMY NOR THE PERSON RESPONSIBLE FOR OBTAINING THE MEDICAL AID WILL BE RESPONSIBLE FOR THE EXPENSE INCURRED.

Answer Required

YES, I understand

Student Health Information

Please upload a copy of the student's Immunization Record

Answer Required

Choose a file or drag it here.

Please explain any "Yes" answers from above

Answer Required

Describe any other important health-related information about your child

Answer Required

List all prescription, over-the-counter, and herbal medications your child takes regularly

Answer Required

STOP -- Administrative Staff Only

Answer Required

Please fix the highlighted areas below before submitting.

Student Medical History