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ASTORIAN

HILL SCHOOL

Student's First Name

Preferred Name

Student's Date of Birth

Student's Last Name

Gender

Phone Number

Address

Email Address

Nationality

Father's Name

For Foreign/Dual Citizen:

Mother's Name

Contact Person

Does your child have any allergies (to medication, food or others) that you are aware of?

Does your child have any illness or disability that the school may need to be aware of?

Does your child receive any medication or other medical treatment either regularly or occasionally?

Has your child ever been hospitalized for any reason?

If you know your child's Blood Type, please indicate

Do you have a family doctor?

Has your child ever receive a FLU Shot?

Form Completed By:

Use tab to navigate through the menu items.

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