NEISD Travel Consent/Health Form

Due by August 31, 2018

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Student

First Name

Last Name

Date of Birth

YYYY

Insurance (primary)

Insurance Company

Policy Number

Group Number

Name of policy holder

Insurance (secondary)

Insurance Company

Policy number

Group Number

Name of policy holder

Dental

Insurance Company

Policy Number

Group Number

Name of policy holder

Health Related information about student

List allergies to food, medications, other. If none, so state.

Special health concerns. If none, so state.

Date of last tetanus vaccine

YYYY

Name of Student's physician

Name of Student's dentist

Parent/Guardian Name

First Name

Last Name

Relationship

Home phone

(###)

###

####

Work phone

(###)

###

####

Cell phone

(###)

###

####

North East Independent School District

I understand that North East Independent School District does not assume any financial responsibility, but will arrange for emergency care. By signing this form you are giving the appropriate school personnel authority to call EMS to transport and to obtain emergency medical care.

Parent/Guardian Signature

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