*Last Name: *First Name: Middle Initial:

*Date of Birth – Month: Day: Year: Gender: OSIS ID:

*Last Name: *First Name: *Relationship:

Preferred Language of Communication – Written: Oral:

Home Telephone: Work Telephone: *Cell Phone: *Email:

*Address: Apartment: *City: *Zip Code: *Borough:

Last Name: First Name: Relationship:

Preferred Language of Communication – Written: Oral:

Home Telephone: Work Telephone: Cell Phone: Email:

Address: Apartment: City: Zip Code: Borough:

*Name: *Telephone: *Relationship:

Name: Telephone: Relationship:

Name: Telephone: Relationship:

Name: Relationship: Order of protection?YesNo

Name of Physician/Clinic: Telephone:

Health Alert
Does child have any health condition that may affect participation in physical activities? YesNo
Limitations:
(e.g., stair climbing, participation in gym)

Allergies:

504 services for the current year?YesNo Previous year?YesNo

My Child has private health insurance:Private health insuranceMedicaidMy Child has no health insurance
If “No Health Insurance,” are you willing to share contact information from this card to learn about insurance options?YesNo

If none of the named contacts can be reached what do you wish the school to do if your child is sick or injured:

It is understood that in the final disposition of an emergency case, the judgment of the school authorities will prevail.
The recommendation of the parent as indicated above will be respected as far as possible.

Last Name: First Name: School of Attendance:

Last Name: First Name: School of Attendance:

Last Name: First Name: School of Attendance:

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