STUDENT INFORMATION, EMERGENCY CONTACT

AND TREATMENT RELEASE AND MEDICAL INFORMATION 

2008-2009

Please complete every line, or indicate with n/a if it does not apply.

Student’s Name                                                                                                                                                                                                                 Grade                                                                                                                                                                                                                                     Grade:                    

                                                       Last                                            First                                              Middle

Student’s Birthdate                                                       Place of Birth                                                                                   School District                                       

                                          Mo          Day      Yr                                             

Father’s Name                                                                                                      Mother’s Name                                                                                                                                                                                                                                                                               Last                     First                                                                         Last                             First          (Maiden)

                                        Last                        First                                                                                                Last                  First                 (Maiden)

Home Address                                                                                                     Home Address                                                                                                                                                                                                                                    

                                                                                          Zip                                                                                                                                                 Zip                    

Place of employment                                                                                        Place of employment                                                                                                                                                                                                      

Phone: Home                                Work                           Cell                          Home                                Work                                   Cell                                                                     

Email______________________________________­­­­­­____________    Email________________________________________________________

Religion/Church you attend                                                                        Religion/Church you attend                                                                                                                                                                    

Student baptized Roman Catholic?          yes          no                                           

*Please Note:  If there is an active “Court Order” that affects the school, a copy needs to be supplied to principal, please.

EMERGENCY CONTACT:  In case of emergency and parent/guardian cannot be reached, St. Thomas must have the name and telephone number of three people whom we may call.  The Oregon Employment Dept., Child Care Division, requires that we have at least two (2) people who have been authorized to pick up your children in case of emergency.

                  Name                                                                               Phone                                                             Relationship to Child

                  Name                                                                               Phone                                                             Relationship to Child

                  Name                                                                               Phone                                                             Relationship to Child

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                  EMERGENCY TREATMENT RELEASE:  Please initial each paragraph and sign & date where indicated.

________  I/We voluntarily consent to the rendering of such care, including diagnostic procedures, surgical and medical treatment, and blood transfusions, by authorized members of the hospital staff or their designees, as may in their professional judgment be necessary.

________  I/We hereby acknowledge that no guarantees have been made to me as to the effect of such examinations or treatment of my child’s condition.  I/We have read this form and certify that I/we understand its contents.  I/We hereby give our consent to the staff at St. Thomas Academy who will be caring for my/our child during the period of August 2008 - June 2009 (school year or portion thereof) to arrange for emergency medical/dental care and treatment necessary to preserve the health of my/our child.  I/We acknowledge that I/we are responsible for all reasonable charges in connection with care and treatment rendered during the period stated above.

_______ In an emergency, St. Thomas Academy has my/our permission to call an ambulance, or take my/our child to any available physician or hospital at my/our expense.

_______ In case of an emergency, a parent or guardian is expected to meet the St. Thomas Academy staff person at the hospital or physician’s office as soon as possible.

                                                                        Signature                                                                                                                                                                                                                                                                     

                                                                                              Circle one:   Mother      Father      Legal Guardian               Date

MEDICAL INSURANCE INFORMATION

Physician:                                                                                                                                                                                                                                                         

                                     Name                                                            Address                                                                        Telephone                                                                                                                                                                                          

Name of Insurance Carrier                                                                                           Group #                                     Agreement #                                                                                            

Name of person/company under whom insurance is carried                                                                                                                                                                                                                                                                                                                

Medicines the child routinely takes                                                                                                                                                                                                                                                                                                                                                                                                                         

Allergies                                                                                                                              Date of last tetanus booster