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Immunization and Student Medical Treatment Authorization 2021-22

In accordance with New Mexico State Law, we require that an updated immunization record for each student be on file in order for that student to attend Rio Grande School. Your child cannot come to school if the immunization record is not up-to-date. This means we have to receive it in time to process it before the first day of school.

Please send us this information as soon as possible, so that our school records can be updated in advance of the beginning of the school year. You may have your doctor provide your child’s immunization record, or you may copy your child’s immunization card and provide it to us. You can fax it to us at 505-986-0012.

Alternatively, if you do not follow the required New Mexico schedule of vaccines, you need to complete a Certificate of Exemption form, have it notarized, and get approval from the New Mexico State Department of Health. You can download the form from the Department of Health website at https://www.nmhealth.org/publication/view/form/454/ Please provide a copy of the approval to RGS.

For all students, new immunization records must be submitted every year. *

Answer Required

My child's up-to-date immunization record is attached (or DOT medical exemption approval, these expire and need to be updated every 9 months) .

I will return my child's updated immunization record (or DOT medical exemption, these expire and need to be updated every 9 months) by the first day of school.

Please upload a copy of your child's immunization records or DOT medical exemption form here.

Answer Required

Choose a file or drag it here.

Rio Grande School Student Medical Treatment Authorization. Please complete this form for each student in your household who attends RGS. Parents are responsible for updating information as changes occur during the year.

Student Full Name *

Answer Required

Student's Date of Birth*

Answer Required

Students Gender*

Answer Required

Male

Female

Student's Grade (beginning in fall of 2021)*

Answer Required

Name of Student's Legal Gaurdian(s)*

Answer Required

Student lives with: *

Answer Required

In case of an emergency, provide the following information for the student's physician or medical facility:

Name of Physician/facility: *

Answer Required

Address of physician/facility:

Street Address*

Answer Required

City*

Answer Required

Zip/Postal*

Answer Required

Phone of students physician/facility: *

Number Required

Authorization for Medical Treatment:

I hereby authorize the Head of School, or another responsible agent of the Rio Grande School, to authorize a licensed physician to administer to my child (ward) such medical treatment as said physician may deem necessary or advisable for my child’s (ward’s) present or future health, if it is impossible to contact a parent or legal guardian.

I give my permission for Emergency Medical transportation. I agree to pay all necessary and responsible costs of medical treatment, transportation, and hospitalization. I also waive and release the person designated above and the Rio Grande School of any loss, claim, or liability that may result from utilization of such action

Today's Date*

Answer Required

Name of Parent or Guardian (this counts as an electronic signature) *

Answer Required

Insurance Carrier*

Answer Required

Policy number*

Answer Required

Confirmation Email

Confirmation Email *

Email Required