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Owyhee Community Health Facility A governmental entity of the Shoshone-Paiute Tribes Sho-Pai Managed Care Program P. O. Box 130 Owyhee NV 89832 Phone 775 757-2415 Fax 775 757-3010 STUDENT HEALTH FORM 2009/2010 THIS SECTION IS TO BE COMPLETED BY THE STUDENT NAME LAST FIRST DATE OF BIRTH MI CHART NUMBER TRIBE ENROLLMENT NUMBER INSURANCE NAME PHONE NUMBERS NEEDED WHILE ATTENDING SCHOOL* HOUSING TELEPHONE CELL PHONE ADDRESS INSURANCE PHONE NUMBER EMERGENCY CONTACT INFORMATION PHONE RELATIONSHIP...
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