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King william high school


Tel: (804) 769-3434

KING WILLIAM HIGH SCHOOL
Fax: (804) 769-2430
80 CAVALIER DRIVE
KING WILLIAM, VA 23086
STUDENT DATA FORM 2012-13

Child’s Legal Name:
*see principal if there is a concern with sharing this information. Student Resides with: Both Parents _____
Father/Male Guardian’s Name

Mother/Female Guardian’s Name

SchoolMessenger Contact Information
Our automated parent information system, SchoolMessenger, calls your home with important news about school
closings and delays, PTA meetings, special events, etc. In the event of a daytime weather emergency such as an early
closing, we need daytime phone numbers to call. These can be parent work numbers, cell phone numbers, or your
emergency contacts. Please list these numbers below. Note: the SchoolMessenger system can call only direct
numbers. It can’t reach extensions.
Use my Emergency Contacts for SchoolMessenger: Yes _____ or Use Contacts Below _____
SchoolMessenger daytime contact #1: Name:
SchoolMessenger daytime contact #2: Name:
Emergency Contacts (If Parents/Guardians Cannot Be Reached):

Please complete and sign back page of this form.
List all students who reside in this household and attend King William County Public Schools:
Please list ANY MEDICAL CONDITION THAT YOUR CHILD HAS: such as asthma, diabetes, seizures, heart
condition, severe allergic reactions, skin condition, immuno-suppression, any medication taken regularly, nose bleeds,
migraines, frequent headaches, anxiety disorder, etc. Please call the school nurse at 769-3434, ext. 606, to review
this information and to have any needed medications in the clinic and plan on file.

Insurance and Physician Information:
Do you have health insurance? Yes

Physician’s Name:

Medical Permission:
In the event of a medical/surgical emergency, every effort will be made to contact the parents or legal guardian. In the
event that the parents/legal guardians cannot be contacted, we will need your permission to seek treatment for your
child. This medical permission will apply to incidents occurring during school hours, on field trips, or during school
sponsored activities.
I hereby grant permission for my child to receive medically necessary emergency treatment including transportation to
treatment:
Child’s Name:
, (do ___) (do not ___) authorize my child’s health care provider and designated
provider of health care in the school setting to discuss my child’s health concerns and/or exchange
information pertaining to this form.
This authorization will be in place until or unless you withdraw it. You may
withdraw your authorization at any time by contacting your child’s school. When information is released from your
child’s record, documentation of the disclosure is maintained in your child’s health or scholastic record.
Signature of Parent or Legal Guardian


Emergency Medication Permission:
In case my child has an elevated body temperature greater than 101°F, and you cannot reach me or my emergency
contacts, the school has permission to administer Acetaminophen (Tylenol) dosed on his/her body weight. I
understand that I am still responsible to have my child picked up from school as soon as possible.

Medical Condition Notification:
I grant permission for my child’s medical condition(s)/picture to be shared with essential King William County Schools
personnel (such as bus drivers, teachers, etc.).

Source: http://www.kwcps.k12.va.us.schools.bz/docs/StudentDataFormKWHS-0.pdf

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