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Student personal data sheet 2002-2003

BROOKWOOD JUNIOR/SENIOR HIGH SCHOOL
STUDENT PERSONAL DATA SHEET 2013-14
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We need a current Student Personal Data Sheet in our office at all times in case of an emergency. This form should be
completed by a parent/guardian. Please return completed form to the high school office as soon as possible. We would
appreciate being notified when any of this information has changed.

SCHOOLS ARE REQUIRED BY STATE LAW TO COLLECT THE FOLLOWING INFORMATION!
STUDENT INFORMATION
Name of Student (Please Print):____________________________________________________________________
Legal name as it appears on Birth Certificate Last Name First Name Middle Name
Enrolling in Grade:_____ Gender:______ Age: ______ Race:____________ Year of Graduation: _______________
Address: ________________________________________________ City: _________________ State: ___________
Zip Code: __________ Telephone #: ___________________________________ Date of Birth: _____/_____/_____
Birthplace: ____________________ Birth Country:___________________ Social Security #: __________________
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PARENT/GUARDIAN INFORMATION: STUDENT IS LIVING WITH __________________________________
Female Parent/Guardian Relationship:

Name:____________________________________________________________________________________________
Mailing Address: ____________________________________City:______________State: _________ Zip:___________
Home Phone: __________________________________E-Mail: _____________________________________________
Employer:________________________________________Occupation:_______________________________________
Work Address: ________________________________________ City:______________ State:__________ Zip:_______
Work Telephone:____________________________________ Ext:____________ Work Hours:_________--_________

Male Parent/Guardian Relationship:

Name:___________________________________________________________________________________________
Mailing Address: ________________________________ City:________________ State: _________ Zip:___________
Home Phone: __________________________________E-Mail: ____________________________________________
Employer:________________________________________Occupation:______________________________________
Work Address: ______________________________________ City:_______________ State:__________ Zip:_______
Work Telephone:___________________________________ Ext:____________ Work Hours:_________--_________
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MEDICAL AND EMERGENCY INFORMATION
Occasionally a student may request medicine from the staff for a minor symptom. We offer Tylenol and Ibuprofen but we must have
the following information filled out in order to give the medication as needed. If your child is on a daily medication, please request a
form from the school nurse or from the High School Office.
Local Person to contact (other than self): _____________________________________________ Phone:_______________________________
RELATIONSHIP WITH STUDENT: _____________________________________________________________________________________
Doctor’s Name:____________________________________________ Clinic:______________________ Clinic Phone:____________________
Special Health Concerns (e.g. allergies, asthma, etc.):_________________________________________________________________________
Permission to give Tylenol / Ibuprofen: _________ Yes ________ No
I GIVE PERMISSION FOR MY CHILD TO RECEIVE THE ABOVE MEDICATION DURING THIS SCHOOL YEAR AS DIRECTED.
Parent/Guardian Signature: _________________________________________Date:____________________________
If I am unable to be contacted, I hereby give my consent to the school authorities to take the above named child to a physician in case of an emergency
or serious illness, deemed so by school authorities, and give my permission to the physician to perform any necessary treatment of my child.

Parent/Guardian Signature:_________________________________________Date:____________________________
DO WE HAVE PERMISSION TO RELEASE YOUR CHILD’S NAME TO VARIOUS ORGANIZATIONS SUCH AS COLLEGES, RECRUITERS, ETC. FOR THEIR

INFORMATION? YES ______ NO ________

Source: http://www.now.k12.wi.us/brookwood/forms_documents/STUDENT_PERSONAL_DATA_SHEET_2013-14.pdf

Volume_101-2_page

HISTORY OF PUBLIC HEALTH A Canada-Brazil Network in the Global Eradication of SmallpoxSteven Palmer, PhD,1 Gilberto Hochman, PhD2The year 2010 marks the 30thanniversary of the global eradi- study Medicine at Queen’s University was thwarted by admissionscation of smallpox, the only public health effort in history topolicies favouring returning veterans. Instead he took his MD ateradicate

Cvmedlegal_feb 2012

CURRICULUM VITAE MICHAEL NATHANSON MB BS, MRCP, FRCA CONSULTANT ANAESTHETIST NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST QUEEN'S MEDICAL CENTRE NOTTINGHAM PERSONAL DETAILS Professional Address Nottingham University Hospitals NHS Trust Telephone Date of Birth Place of Birth Nationality Registration Present Appointment Clinical

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