Blue card form | Landmark HS

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Landmark High School

Student Information

Student First Name *

Student Middle name

Student Last Name *

Date of Birth *

Month

Day

Year

Osis Number*

Primary Guardian Information

This Guardian can

Be Contacted in emergencies

Pick Up a student

Receive school Mailings

Guardian First and Last name ( who the student resides with) *

Relationship to student*

Preferred Language of communication *

Home Phone *

Mobile Phone *

Ok to text *

Yes

No

Work Phone *

Email Address *

Street Address *

City*

State *

Zip Code *

Additional Guardian Information

This Guardian can

Be Contacted in emergencies

Pick Up Student

Receive School Mailings

First Name *

Last Name *

Relationship to student *

Email Address *

Home Phone *

Mobile Phone*

Okay to text?

Yes

No

Work Phone *

Street Address

City *

State*

Zip Code *

Emergency Contact Information

List Below the names of three additional people who may be called in case of emergency or if child is sick in school

Name*

Email Address*

Phone*

Name*

Email Address*

Phone*

Name*

Email Address*

Phone*

No Access: If there is a person who MAY NOT HAVE ACCESS to child please indicate

Name

Order of protection

Yes

No

Effective date of court order

Health Information

Name of Physician/ Clinic

Physician/ Clinic phone

Physician

Allergist/Immunologist

Cardiologist

Dermatologist

Development/behavior specialist

Neurologist

Pulmonologist

other

Does child have any health condition that may affect participation in physical activities?

Yes

No

Other

Known Diagnoses ( Check all that apply)

Asthma

Seizure

Allergies/Anaphylaxis

Diabetes

None

Other

Allergies

Milk

Eggs

Peanuts

Tree Nuts

Fish

Shellfish

Soy

Wheat

Other

My child has

Private health insurance

Medicaid

No Health Insurance

It is understood that in the final disposition of an emergency case, the judgement of the school authorities will prevail. The recommendation of the parent as indicated above will be respected as far as possible

Please list the names of any siblings and what schools they attend

Signature of parent/guardian

By checking this box, I agree to be Contacted by School, District , and/or City-WIde Parent leader volunteers regarding events, updates, and other matters connected to my school community

By checking this box, I agree that my contact information can be shared with elected School, District, and / or Citywide parent leader volunteers so I can be updated on events and other matters connected to my school community

Signature*

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Confirmation email *

Landmark High School Telephone: 212-647-7410 Instagram: @Landmark_hs

351 West 18th Street , NY, NY 10011

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