Santa Fe Public Schools - Student Profile - 2016-2017 Student's Name: Doe, Jane

Student Number: 86006

School: Santa Fe High School Gender: Female Birthdate: 03/12/1984 Race: Non-Hispanic Ethnicity: Caucasian

Grade: 9 Birth Place: Tribe: Other

Please check all information on both sides of this form. If anything is incorrect or missing enter the information below in the white area indicated with an arrow. Make sure you sign the form in ALL three places indicated by the red arrows. Return this form to your child's school no later than March 24th, 2016. It is extremely important that the school has your most up-to-date information to ensure we can reach you in the case of events or emergencies.

1. STUDENT / PARENT / EMERGENCY CONTACT INFORMATION: Street Address: 610 ALTA VISTA

City: SANTA FE

State: NM

Zip: 87505

New Street Address:

City:

State:

Zip:

If you have entered a change of street addresss, you are required to submit 2 proof of address to the school site within 30 days.

Mailing Address: 610 ALTA VISTA

City: SANTA FE

New Mailing Address: Home Phone: 505-467-2590

City: Alternate Home Phone:

(for automated calls)

(for automated calls)

In which language would you like to receive communication?

New Home Phone: Mother's Education Level (Circle One):

New Alternate Home Phone: High School Diploma Bachelor's Doctorate

State: NM

State: Zip: Student Cell Phone: Spanish

English

New Student Cell Phone:

Associate's Father's Education High School Diploma Master's Level (Circle One): Bachelor's Don't know Doctorate

Contact #1 BAMBI DOE (Mother/Guardian): Home Phone: 505-467-2590

Relationship: Mother Cell Phone:

Email: Work Phone:

New Contact #1 (Mother/Guardian): Home Phone: Contact #2 JAMES DOE (Father/Guardian): Home Phone:

Relationship: Cell Phone: Relationship: Father Cell Phone:

Email: Work Phone: Email: Work Phone:

New Contact #2 (Father/Guardian): Home Phone: Contact #3:

Relationship: Cell Phone:

Email: Work Phone:

Home Phone:

Relationship: Cell Phone:

Email: Work Phone:

Home Phone:

Relationship: Cell Phone:

Email: Work Phone:

Home Phone:

Relationship: Cell Phone:

Email: Work Phone:

Home Phone:

Relationship: Cell Phone: Relationship: Cell Phone:

Email: Work Phone: Email: Work Phone:

Home Phone:

Relationship: Cell Phone:

Email: Work Phone:

New Contact #3: Contact #4: New Contact #4: Home Phone: Contact #5: New Contact #5:

Go to back of form

Zip: 87505

Associate's Master's Don't know

Student's Name: Doe, Jane

Grade: 9

Student Number: 86006

2. STUDENT'S HEALTH INFORMATION: Doctor:

Please contact the school nurse with any change in your child's health. Phone:

New Doctor: Dentist : New Dentist :

Phone: Phone: . Phone:

Student's Insurance : New Student Insurance:

Subscriber's Name: Subscriber's Name:

Insurance #: Insurance #:

ALL MEDICAL QUESTIONS MUST BE ANSWERED - NO QUESTION CAN BE LEFT BLANK Can your student be given: (Circle Yes or No) Tylenol Ibuprofen Chewable Antacids (Tums) Non-medicated cough drops

Circle One Yes No Topical antibiotic Yes No cream (Neosporin) Yes No Anti-itch hydrocortisone cream Yes No Topical oragel (Anbesol)

Circle One Is your child allergic to Yes No any medication? List medications: Yes No

Circle One Yes No

Yes No

Medical Condition Questions: (Circle Yes or No) Circle One Yes No

Asthma with inhaler in the past year ADD/ADHD Diabetes Insulin Hearing Problems Seizures Heart Condition Epipen

Yes No Yes No Yes No Yes No Yes No Yes No Yes No

Is your child allergic to any foods? List food allergies:

Circle One Circle One Daily medications Yes No Yes No at home? List daily medications at school:

Other Medical Conditions: List Here

Other medications need additional consent forms in order to be given at school. Contact your school nurse. DO NOT SEND MEDICATIONS WITH YOUR CHILD TO SCHOOL. Parents must personally deliver medications to the school nurse in their original container. (This includes emergency medications.)

In case of an emergency involving my child and I cannot be reached, I hereby give consent to transport my child to the nearest medical facility and authorize the health care provider(s) at said medical facility to administer reasonable and customary medical and health care deemed necessary by said health care provider(s). This authorization does not cover major surgery unless one other doctor/dentist concurs with the recommended treatment of the initial treating health care provider. Nothing in this section shall be construed to impose liability on any school official or school employee who, in good faith, attempts with the provisions set forth in this section. I understand that I will be financially responsible for all emergency and follow-up care associated with this medical emergency.

Parent Signature:

Date:

3. Santa Fe Public School Releases:

Circle Yes or No if you wish to change Last Year your response Response: from year Yes lastNo I give my permission for my child to be interviewed, photographed or videotaped by media representatives. Yes No I give my permission for my child's artwork to be displayed and/or published in SFPS publications (i.e. calendar, fliers, etc.). Yes

No

I give my permission to allow my child's photo to be published on the SFPS district websites.

Yes

No

I give my permission for my child's directory information to be disclosed.

Yes

No

I give permission for the parent email address(es) listed to be contacted for student and district purposes.

Yes

No

I give my permission for my child to be contacted by a military recruiter (11th and 12th grade only).

Parent and student initial below for Behavioral Expectations for Students

I will read and adhere to the Santa Fe Public Schools Behavioral Expectations for Students Parent Initial

Student Initial

I agree that all information provided on this document is true and accurate to the best of my knowledge and that I have legal authorization to represent this student. Any change in address, mailing address or phone numbers must be provided to the schools within 30 days of the change.

Parent/Guardian Signature

Date

Student Signature

Date