Last Name (print)
Address
    ___ 1     1_-
Date of Birth
Current Medications
Family History:
Age
Father
Mother


First Name
City
Sex:     M     F

State of Health


Occupation


Middle Initial
State
Age at Death


(Maiden)
Zip
Cause of Death



Spouse
Children
    Brother(s)     .
Sister(s)
Student's Personal History:
Diabetes
Cardiac Device
VNS Device
Down Syndrome
Prader Willi
Seizure Disorder
Encephalopathy
PDD
Autism
Asperger's Syndrome
Hearing Impairment
Visual Impairment
Legally Blind
Fetal Alcohol Syndrome
Anxiety
Depression
Schizophrenia
OCD
ADHD/ADD
Bipolar
    OTHER:     _ 

---

Signature of Student or Parent/Guardian
Date
Student's First Name


Middle Initial


Last Name


Maiden Name (if applicable)



    Student's Local Address or Residential Program Address     City     State     Zip Code
    Student's Residential Advisor (if known and applicable)             D.O.B. __ / __ /     _
    (___)     L_),     ---------,--------     _
Student's Local Phone Number Student's Cell Phone Number



    Mother's Name     _
    P.O. Box or Street,     _
    Ciry,State,ZIP ___
Horne Number     -,-     Ce\I     _


Father's Name
P.O. Box or Street,     _
City, State, ZIP     -r-r-     _
    Home Number     Cell     _



    Work Number     Work Number     _
AFTER COMPLETING THE ABOVE, PLEASE ~THE ONE NUMBER THAT IS BEST TO REACH YOU
    Parent/Guardian email address -r-r-     (to communicate events, school closings, information, etc.)
(or write N/A if you do not have an email address)



Legal Guardianship:
I will/did receive my:


__ I DO NOT have a legal Guardian
Certificate of Attainment


__ I DO have a legal Guardian (please provide documentation)
__ High School Diploma or equivalent "



    Insurance Company (or write N/A if you do not have medical insurance)     _



Insurance Co, Name
Signature of Applicant/Guardian:     _


Insurance Policy #
Date:     _