King's Daughters Health System

Please read carefully: In order for King’s Daughters (“KDMC”, “we” or “us”) to see a student at the school indicated below, all pages of this form must be completed by the student’s parent or legal guardian, signed and dated in the appropriate places. Consent is for the 2023-2024 school year and may be withdrawn at any time in writing by the signatory below.

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Your First Name:

Your Last Name:

Your Email Address:

Would you like for your child to access all of these services?

Student Information

Todays Date:

School Name:

Student First Name:

Student Last Name:

Gender:

Date of Birth:

Last 4 SSN:

Address:

City:

State:

Zip:

Home Phone:

Mobile Phone: