Student's Information
Church Affilliation
Elementary School
Primary Family Information
Father's Information
Mother's Information
Step Father's Information
Step Mother's Information
Emergency Contacts other than parents
Medical Contacts
A physical exam is required for a child upon enrollment at RHCDC. Immunization records are to
be submitted immediately, and when new immunizations occur or at the request of RHCDC.
We give permission for sunscreen to be applied according to state regulations:
RHCDC agrees to notify the parent/guardian whenever the child becomes ill and the parent/
guardian agrees to arrange for immediate pick-up of child if so requested.
The parent/guardian authorizes RHCDC to obtain immediate medical care for our child. In the
event we cannot be reached, we the parent/guardian grant our consent for the hospital and its
medical staff to provide my/our child with emergency medical treatment which a physician
deems necessary, to include anesthesia. We also understand that our child may be taken to the
nearest hospital or medical facility. I/We agree to accept financial responsibility for all expenses incurred
Pickup Information
Pick Up Authorization (list names of any person who may not pick up your child from RHCDC)
