Student Health Information

Youth Initiative High School
Boarding Student Application for Admission

Student Health Information

* Indicates required field

Student Name *

First

Last

Insurance Information

Insurance Company Name and Address *

Policy # *

Will this policy cover student in Wisconsin? *

Youth Initiative High School requires all students with Health Insurance to submit proof of insurance with relevant contact information to YIHS staff.

Local Emergency Contact Information ( if you do not have a host family yet, leave this blank):

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Relationship to Applicant *

Health Information:

Does your child take any medications on a regular basis? (please list) *

Does your child have any allergies, including insect stings? Please list. *

Has your child ever had seizures? If so, please explain. *

Can your child be given any of the following in case of minor injury of headache? Please check all that apply. *

Homeopathic remedy Aspirin Tylenol Ibuprofen

We are required by law to keep all student's vaccination records on file.

Domestic Boarding Students:
Download, fill out, and return this required form before student arrives at YIHS.
http://www.dhs.wisconsin.gov/forms/F0/F04020L.pdf

International Boarding Students:
After we receive your application, we will send you an immunization form. This form must be filled out and returned before student can attend YIHS.

I understand immunization records are required for my student to attend YIHS *

Yes No

I hereby give my consent for EMERGENCY MEDICAL CARE OR TREATMENT

Parent's Signature *

Date *

Submit and Continue to Student Tuition Agreement

Youth Initiative High SchoolBoarding Student Application for Admission

Student Health Information

Youth Initiative High School
Boarding Student Application for Admission