AMPHITHEATER SCHOOL DISTRICT
HEALTH INFORMATION CARD
Revised 1/18 Stock Form #W9072
City State Country
Name/Address of Person(s) with whom Student may reside:
Name Address (If different than above) Home # Work # Cell #
Father _________________________________________ _______________________________________ ____________ ____________ ____________
Step-Father _____________________________________ _______________________________________ ____________ ____________ ____________
Mother ________________________________________ _______________________________________ ____________ ____________ ____________
Step-Mother ____________________________________ _______________________________________ ____________ ____________ ____________
Guardian ______________________________________ _______________________________________ ____________ ____________ ____________
Brothers/Sisters:
Name __________________________ Age _____ School ________________ Name __________________________ Age _____ School _________________
Name __________________________ Age _____ School ________________ Name __________________________ Age _____ School _________________
Name __________________________ Age _____ School ________________ Name __________________________ Age _____ School _________________
Any legal restricted custody decision the school health ofce should be aware of? If yes, describe: ____________________________________________________
Language(s) spoken by Student _______________________________________ Language(s) spoken at home _______________________________________
PLEASE PRINT
TEACHER'S NAME (School Use Only)
________________________________
PLEASE CHECK THE FOLLOWING ITEMS, IF THEY PERTAIN TO YOUR STUDENT:
qADHD/ADD q Allergies/drug q Allergies/food q Asthma q Birth defects q Blood disorder q Bowel/bladder
q Diabetes q Glasses/contacts q Headaches/migraines q Hearing problem q Heart condition q Orthopedic q Psychiatric disorder
q Seizure disorder q Other (If any items were checked, please explain) ________________________________________________________________
If your student is to take medication at school, a signed consent form is required.
Please list all medication(s) student is now taking at home or school: ____________________________________________________________________________
What health or physical problem might affect school attendance or participation in PE? _____________________________________________________________
Has your student ever been involved in a special education program? If yes, please explain __________________________________________________________
INSURANCE COVERAGE: q None q AHCCCS q Kids Care q Indian Health Services q Other Health Plan _________________________________
Doctor ________________________________________________ Phone _______________________ Hospital Preference ______________________________
If parent/guardian cannot be reached, name a relative or friend with a LOCAL PHONE who will be responsible for your student if he/she is hurt or becomes
ill at school. (Please notify the school health office of any information changes on this card.
Name___________________________________Address___________________________________Phone(s)_________________________ Can pick up
Name___________________________________Address___________________________________Phone(s) _________________________ Can pick up
If emergency medical action or treatment is required, and parent/guardian cannot be contacted, I hereby authorize my child to be given emergency medical care as
deemed necessary by school ofcials. I understand that any expenses incurred will be paid for by the parent/guardian or by insurance coverage provided by the parent/
guardian, and that payment of any medical expense is not the responsibility of the school or the school district.
Parent/Guardian Signature _______________________________________________________________________ Date _________________________________
(Signature veries that all of the information on this card is accurate.)
Amphitheater Unied School District does not discriminate on the basis of race, color, religion/religious beliefs, gender, sex, age, national origin, sexual orientation, creed, citizenship status, marital status, political
beliefs/afliation, disability, home language, family, social or cultural background in its programs or activities and provides equal access to the Boy Scouts and other designated youth groups. Inquiries regarding the
District’s non-discrimination policies are handled at 701 W. Wetmore Road, Tucson, Arizona 85705 by Anna Maiden, Equal Opportunity & Compliance Director, (520) 696-5164, amaiden@amphi.com, or Kristin
McGraw, Executive Director of Student Services, (520) 696-5230, kmcgraw@amphi.com.
M
Full Legal Name of Student________________________________________________________________ Sex______ Grade______ School_________________
F
(Last) (First) (Middle)
Resident Address______________________________________________________________________________________________________________________
Mailing Address (if different) ___________________________________________________________________________________________________________
Date of Birth __________________ Place of Birth_________________________________________________________________________________________
