City Of Seattle-DEEL-UB-Medical and Health Form

Please enter a response for every question on this form, if you do not have an answer please enter N/A.

Student Name

First NameLast Name

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Date

Last 4 of SSN:

Home ph:

(999)999-9999

Cell ph:

(999)999-9999

Parent/Guardian Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home ph:

(999)999-9999

Cell ph:

(999)999-9999

Work Ph:

(999)999-9999

Emergency Contact Information:

Name

First NameLast Name

Relationship to youth

Home ph:

(999)999-9999

Cell ph:

(999)999-9999

Work Ph:

(999)999-9999

DOCTOR / INSURANCE INFORMATION

Primary Care Doctor’s Name

First NameLast Name

Doctor’s Phone Number

(999)999-9999

Health Insurance Information: Medical ID / Group Number

Do you have coverage or go through one of the following for your medical care – Please check

STUDENT HEALTH INFORMATION

Check yes or no for each item listed below

Currently takes medicine:

If yes, list medicine:

Allergic to medicine, food, and/or insect bites:

If yes, list:

Cannot eat some foods for religious or other reasons

If yes, List foods:

Disabilities or physical limitations

If yes, List:

Motion Sickness

If yes, and you take medication, list the medication:

Date of last DPT (Diphtheria/Tetanus) shot

Date

Other important health information

UPWARD BOUND HEALTH INFORMATION & AUTHORIZATION FOR MEDICAL TREATMENT