LEWISVILLE ISD HEALTH AND EMERGENCY INFORMATION

NAME __________________________________________ BIRTHDATE _______________ GR __________ HR ______________

PRINT LAST FIRST MIDDLE MO DAY YR

ADDRESS ___________________________________________________________ HOME PHONE ( )_____________________

ACTUAL LOCATION CITY ZIP

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RESIDES WITH (FULL NAME) RELATIONSHIP PLACE OF WORK WORK PHONE

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RESIDES WITH (FULL NAME) RELATIONSHIP PLACE OF WORK WORK PHONE

OTHER EMERGENCY CONTACTS AND PHONES ______________________________________________________________

USUAL OR EMERGENCY DOCTOR ______________________________________________ PHONE ____________________

KNOWN ALLERGIES BY NAME _____________________________________________________________________________

HEALTH PROBLEMS (ALSO COMPLETE BACK) ______________________________________________________________

PARENT/GUARDIAN SIGNATURE ______________________________________________ DATE ______________________

I GIVE THE SCHOOL PERMISSION TO SECURE MEDICAL ATTENTION IN CASE OF EMERGENCY.

PARENT/GUARDIAN SIGNATURE ______________________________________________ DATE ______________________

I GIVE MY PERMISSION FOR THE PHYSICIANS OF THE ABOVE NAMED STUDENT TO RELEASE INFORMATION ON HEALTH PROBLEMS TO THE LEWISVILLE INDEPENDENT SCHOOL DISTRICT.