HIPAA
Compliance
Contact 1
Please complete the following information for the first emergency contact. The first contact must be the person enrolling the student at LWHS. What is the relationship to the enrolled student? Please Select ParentGuardian What is the name of the first contact? First Name Last Name Cell Phone - Cell Phone Number Home Phone - Home Phone Number Work Phone - Work Phone Number Email - Email Address Should we notify you if the student is sick/injured? Please Select YesNo Should you receive automated emergency calls about the student? Please Select YesNo Should we notify you when the student is absent? Please Select YesNo
Contact 2
Please complete the following information for the second emergency contact. What is the relationship to the enrolled student? Please Select ParentGuardian What is the name of the first contact? First Name Last Name Cell Phone - Phone Number Home Phone - Phone Number Work Phone - Phone Number Email - Email Should we notify you if the student is sick/injured? Please Select YesNo Should you receive automated emergency calls about the student? Please Select YesNo Should we notify you when the student is absent? Please Select YesNo Can this person pick up the student from school? Please Select YesNo Can this person access the student's records? Please Select YesNo Does the student live with this person? Please Select YesNo Is this person allowed personal contact with the student at school? Please Select YesNo
Contact 3
Please complete the following information for the third emergency contact. What is the relationship to the enrolled student? Please Select GuardianGrandparentAnutUncleOther What is the name of the second contact? First Name Last Name Cell Phone - Cell Phone Number Home Phone - Home Phone Number Work Phone - Work Phone Number Email - Email Address Should we notify this person if the student is sick/injured? Please Select YesNo Should this person receive automated emergency calls about the student? Please Select YesNo Should we notify this person when the student is absent? Please Select YesNo Should this person be allowed to pick up the student? Please Select YesNo Should this person be allowed access to the student's records? Please Select YesNo Does the student live with this person? Please Select YesNo Is this person allowed to contact the student at the school? Please Select YesNo
Contact 4
Please complete the following information for the fourth emergency contact. What is the relationship to the enrolled student? Please Select GuardianGrandparentAunt UncleOtherAuntUncleOtherType Option 3 What is the name of the second contact? First Name Last Name Cell Phone - Cell Phone Number Home Phone - Home Phone Number Work Phone - Work Phone Number Email - Email Address Should we notify this person if the student is sick/injured? Please Select YesNo Should this person receive automated emergency calls about the student? Please Select YesNo Should we notify this person when the student is absent? Please Select YesNo Should this person be allowed to pick up the student? Please Select YesNo Should this person be allowed access to the student's records? Please Select YesNo Does the student live with this person? Please Select YesNo Is this person allowed to contact the student at the school? Please Select YesNo