School-Based Health Center Registration

Hometown Health Centers, Schenectady

SCHOOL-BASED HEALTH CENTER REGISTRATION

PARENT/GUARDIAN INFORMATION

Mother's Last Name

Mother's First Name

Father's Last Name

Father's First Name

Legal Guardian's Last Name

Legal Guardian's First Name

Relationship of legal guardian to student

Grandparent

Aunt or Uncle

Other

If other, please specify

Contact Information for parent or guardian

Home phone

Work phone

Cell phone

Who is the student’s regular doctor?

Name

Telephone

Address

INSURANCE INFORMATION

Does the child have health insurance?

Yes

Name of Health Insurance Company

Insurance ID #

Group #

Policy Holder

Relationship to patient

Policy Holder’s Date of Birth (m/d/y)

Sex

Female

Male

If your child does not have health insurance, would you like to be contacted by a Hometown Health Centers Enrollment Specialist who can assist you with obtaining free or low-cost health insurance?

Yes

Pharmacy Name

Pharmacy Location

HOMETOWN HEALTH ADMINISTRATIVE USE

HHC Staff Name

Date Completed

Hometown Health Centers, Schenectady

Services