Homebase Profile Update Request Form

Please use this form to request any updates to your member profile on Homebase.

Name

First Last

Non-Medical Updates (Medical Proceed Below)

Please describe in detail what changes you need to make to your profile. You may include updates to your name, email, phone number, address, pickup restrictions, or other guardian information below.

Medical Updates

Are you updating medical information for a student?

Student First & Last Name

Student Grade

Campus Student Attends

Please list the allergy or medical diagnosis.

Explain what symptoms, reactions, etc., your student may experience.

Will your student have an epi-pen or any other type of medication or injectors on campus with them?

Please explain.

Please give a thorough explanation of how our staff should respond in case of exposure or a medical incident/emergency. Please include at what point to notify parents.

Please confirm you have read UHC's Medical/Allergy Policy.

If "no," see link below and read before submitting this form.

https://upstatecoop.org/handbook/allergy-policy-medical-condition-form/

Homebase Profile Update Request Form