Student Health Information Form

Student Health Information Form

Student Information

Student Lives With *
(check all that apply)
Parent's Marital Status *

Other Children in Family

Family Information For Primary Residence

Family Information For Secondary Residence

Second Parent Address

Emergency Contacts Information

Two adults who will assume responsibility for your child if the parent/guardian cannot be reached.

Physician Information

Health Information

* If yes, refer to local health department
Please check the appropriate
Please check the appropriate boxes pertaining to your student.

Parent Consent

  • In consideration of Alpine Academy permitting my child to participate in all activities relating to school, I assume responsibility for my child’s participation and agree that Alpine Academy will not be held liable for any claims or demands of any nature whatsoever which may arise by or be in connection with my child. I further certify that I, the parent or guardian, consent to the performance of emergency treatment as deemed necessary by school personnel or physicians as a result of injury while participating in school activities. I understand that every attempt will be made to contact me prior to such treatment, but in the event that no contact is possible, I authorize the school to act on my behalf. I further agree that if the physician and hospital of my choice is not available in an emergency, the school has my permission to send my child to the nearest available hospital.
  • In accordance with Alpine Academy of Rockford regulations on administering medications in the school, I authorize the nurse or designated person to provide for my child the medications listed below (or their generic equivalent), according to the appropriate dosage for my child’s age and weight or to administer epinephrine (Epi-pen) to any student experiencing a life threatening allergic reaction. I waive any claims I might have against the school, its employees, and agents arising out of the administration of said medication. In addition, I agree to release, hold harmless, and indemnify the School and its employees from any and all claims, damages, causes of action of injury incurred or resulting from the administration of attempts of said medication.

Alpine Academy of Rockford | 5001 Forest View Avenue Rockford, IL 61108 | 815-227-8894

Alpine Academy of Rockford
5001 Forest View Avenue Rockford, IL 61108