2015-2016
Date______________
SUPERIOR ELEMENTARY SCHOOL
Student Name____________________________________________
Grade __________
Home Phone #________________________________ (Please notify the office if numbers change)
Mother/Legal Guardian ___________________cell#____________ Work Phone #___________
Father/Legal Guardian ____________________cell#____________ Work Phone #___________
Mailing Address _______________________ Physical Address_____________________________
Boy ____Girl ____ Date of Birth___________ Born (City)____________________(State)_____
School last attended (Name) _______________________________Phone #___________________
School last attended (City & State) ____________________________________________________
Number of schools attended (including this one)_______________
Parent’s email address:________________________________________________
Place of employment -Father____________________________________________
Place of employment Mother____________________________________________
Number of years completed in school: Father___ Mother___ Number of children in family____
Student’s rank in family _____
Student lives with: Both Parents _____ Father ____ Mother ____ Other_____
Grandparents _____ Aunt ____ Sister ____ Boarding____
Special Health Conditions, Allergies and Medications
Please indicate if your child has:
1. Special Health Conditions: ______Yes _____No (If yes, please
explain)______________________________________________________________________
_____________________________________________________________________________
2. Allergies (including food, medication and environmental) ____Yes ____ No (If yes, please
explain cause, reaction and treatment)
_______________________________________________________________________________
__________________________________________________________________________________
3. Please list all medications your child is taking. If needed during the school day Permission Form
for Medication must be completed and returned to the school nurse prior to medication being
administered at school.
__________________________________________________________________________________
__________________________________________________________________________________
As per the Student Hand book, no medication is to be kept in your child’s desk, locker, or school
bag. All medication is to be kept locked in the nurse’s office at all times.
*Alternate Responsible Persons: (Please notify the office if numbers change) Can the alternate
person(s) pick student up? ___yes ___no
Name_______________________________ Phone # __________________ cell# _______________
Name_______________________________ Phone # __________________ cell#________________
*Please inform these people that they are your choice. Choose someone who is local and would be
available in your absence.
Authorization for Treatment
I hereby voluntarily consent to emergency treatment, first-aid screening, examinations and minor
treatment (such as antibiotic ointment) as may be deemed necessary. I also voluntarily consent to
preventive health screening including vision, hearing, scoliosis, and other screenings as may be
deemed necessary by the school nurse. I give my permission for the school nurse and/or other
designees to administer (according to protocol) the following over the counter medications as needed:
Acetaminophen (Tylenol), Ibuprofen, Benadryl, Tums, cough drops and throat lozenges. When unable
to contact parent or alternative person, I hereby give my permission to the school to authorize
treatment needed, until the parent can be notified.
YES___________ NO___________
I understand and authorize immunization information on my child will be shared with the local public
health departments and entered into an electronic data system, the Montana Public Health Data System
(PHDS). The intent of an electronic immunization registry is to provide a complete and permanent
immunization record for your child.
Parent/Guardian’s Signature__________________________________________
Physician to Notify__________________________________
Phone number_________________________________________