Christ the King Catholic School Seattle

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Information Form: One Completed Form Per Student

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  Student Full Name REQUIRED Please fill out this field. Please enter valid data.
  
  Student birth date and birth place REQUIRED Please fill out this field. Please enter valid data.
  
  Ethnicity
  
  Race REQUIRED Please fill out this field.
  
  Religion. If Catholic, please include location of Baptism Please enter valid data.
  
  Parent/Guardian 1 REQUIRED Please fill out this field. Please enter valid data.
  
  Parent/Guardian 1 Relation to Student REQUIRED Please fill out this field. Please enter valid data.
  
  Parent/Guardian 1 Primary Email REQUIRED Please fill out this field. Please enter an email address.
  
  Parent/Guardian 1 Primary Cell Phone Number REQUIRED Maximum 20 characters Please fill out this field. Please enter a phone number.
  
  Parent/Guardian 1 Alternate Phone Number Maximum 20 characters Please enter a phone number.
  
  Parent/Guardian 1 Mailing Address REQUIRED Please fill out this field.
  
  City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
  
  Parent/Guardian 1 Employer Please enter valid data.
  
  Parent/Guardian 1 Occupation Please enter valid data.
  
  Parent/Guardian 2 Please enter valid data.
  
  Parent/Guardian 2 Relation to Student Please enter valid data.
  
  Parent/Guardian 2 Primary Email Address Please enter valid data.
  
  Parent/Guardian 2 Primary Cell Phone Number Please enter valid data.
  
  Parent/Guardian 2 Alternate Phone Number Please enter valid data.
  
  Parent/Guardian 2 Mailing Address (if different)
  
  Parent/Guardian 2 Employer Please enter valid data.
  
  Parent/Guardian 2 Occupation Please enter valid data.
  
  Student's Physician Name REQUIRED Please fill out this field. Please enter valid data.
  
  Student's Physician Phone Number REQUIRED Please fill out this field. Please enter valid data.
  
  Student's Preferred Hospital REQUIRED Please fill out this field. Please enter valid data.
  
  Student's Medical Insurance and Policy # REQUIRED Please fill out this field. Please enter valid data.
  
  Student's Medical Considerations
  
  Student's Allergies Please enter valid data.
  
  Medications Administered to Student at Home Please enter valid data.
  
  Medications to be Administered to Student at School Please enter valid data.
  
  Medical Permission to treat:
  If emergency treatment is required, and the parent or guardian cannot be reached immediately, I request that the school exercise its own judgment in securing the health and safety of my child. Actions taken may include calling the physician above, calling 911 (giving permission to Medic 1 to administer medical attention, including medications and nursing care deemed necessary according to 911’s contact/physician in charge) and transporting to the hospital listed above or to the nearest emergency center. I agree that, in the event of a disaster such as an earthquake, emergency medical services may be unavailable and school staff may be the sole emergency medical providers.
  
  I Agree Please select this field.
  
  Please list three contacts who can pick up your child and/or be contacted in an emergency. Please include their relation to your student and phone number/s. One contact should be from out of the geographic area. REQUIRED Please fill out this field.
  
  Submit
  
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