Give

Student Information

Student's Name*

First Last

Date of Birth*

Grade*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone*

Cell Phone*

Student Email Address*

Allergies

Medications

Parent /Guardian Information-– First Contact

Name*

First Last

Relationship*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

(if different from above)

Home Phone*

Cell Phone*

Work Phone

Email*

Emergency Contact #1

(In case parents/guardians cannot be reached and are authorized to pick up your child)

Name*

First Last

Relationship*

Home Phone*

Cell Phone*

Work Phone*

Emergency Contact #2

(In case parents/guardians cannot be reached and are authorized to pick up your child)

Name*

First Last

Relationship*

Home Phone*

Cell Phone*

Work Phone*

Are you an International Student?*

Yes
No

International Student

Please provide the contact information of an English-speaking individual residing in the United States.

Name*

First Last

Relationship*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone*

Cell Phone*

Work Phone

In the event of an illness or accident, I hereby authorize Academy of the Holy Family High School to act on my behalf for the student named above in the securing of medical, surgical, psychological and/or dental treatment. In the event of an emergency, I hereby give my permission to the health care provider selected by Academy of the Holy Family High School to hospitalize, secure proper treatment for, and to order injections, anesthesia, or surgery for the student named above. If such an event occurs, I understand that every effort will be made to contact me as soon as possible. I certify that I am the parent/guardian or have the legal ability to sign these authorizations on behalf of the student named above. I understand I am responsible for all expenses that the above named students insurance does not pay.

Parent/Guardian Initial Here*

Date*

I give Academy of the Holy Family Health Office permission to obtain/provide/exchange information with any health care provider or health care facility. This includes but is not limited to hospitals, walk-in centers, emergency care centers and individual physicians that my daughter may be sent to for medical or psychological evaluation and treatment. This exchange of information includes staff responsible for the health and well-being of student. I understand that I may withdraw my consent at anytime by providing a written request limiting the exchange of information. The Family Right to Privacy Act will protect information placed in my daughter’s school health record.

Parent/Guardian Name*

First Last

Relationship*

Parent/Guardian Signature*

Date*

Medical Card for Coach

This form will accompany the athlete to the doctor or hospital if medical attention is required.

Name of Medical/Accident Insurance Company*

Phone*

Policy Holder Name*

First Last

Policy Holder SS#*

Policy Holder Date Of Birth*

Address of Policy Holder*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Policy No.*

Group No.*

In the event I cannot be reached, I hereby authorize and grant to the staff of Academy of the Holy Family School permission to administer or obtain medical care, perform any necessary treatments, and/or administer medication to my daughter. When necessary, I give my permission for the staff at Academy of the Holy Family to seek and obtain medical treatment for my daughter on an emergency or as needed basis at a licensed hospital, clinic and/or a licensed physician, nurse practitioner or physician’s assistant.

Parent/Guardian Signature*

Date*

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Comments

This field is for validation purposes and should be left unchanged.

Quick Links

ACKNOWLEDGEMENT OF WARNING BY STUDENT

ACKNOWLEDGEMENT OF WARNING BY PARENT

Step 1 of 8

Parent/Guardian Information

Applicant's Academic Information

Part Two: What About Me?

Application Fee

Step 1 of 7

Parent/Guardian Information

Applicant's Academic Information

Part Two: What About Me?

Student Information

Parent /Guardian Information-– First Contact

Emergency Contact #1

Emergency Contact #2

International Student

Medical Card for Coach

Activity	Grade Level	Positions Held/ Honors Awarded

Activity	Grade Level	Positions Held/ Honors Awarded