Please fill out completely. Due September 1, 2018
  • Transportation

    Please indicate the method of daily transportation - Car Rider or Bus Rider. If Central Dauphin Bus, please indicate the bus number. All other school districts, please indicate school district name only.
  • If student is a Bus Rider, please enter the Central Dauphin bus number or other school district name.
  • If student is a Bus Rider, please enter the Central Dauphin bus number or other school district name.
  • Medical Information

    Medications cannot be dispensed by the school without a doctor's order, parent permission and medicine in a proper container. This includes all over the counter medications
  • Please list each condition on a separate row.
    Add a new row
  • Authorization

    If emergency treatment is required, and the parents or legal guardian cannot be reached immediately, your signature is the space provided below empowers the school authorities to exercise their own judgment in calling the physician indicated above, or if not available, to have your child transported by ambulance (if necessary) to a hospital emergency room. Your signature below is not sufficient for the release of confidential information protected by Federal Law.
  • Please enter your full name below.
  • This field is for validation purposes and should be left unchanged.