STUDENT HEALTH RELEASE 2024-2025

HEALTH RELEASE FORM 2024-2025
STUDENT NAME*
STUDENT CELL*
STUDENT DOB*

MonthDayYear
Date
CURRENT GRADE (2024-2025)*
GENDER*
PARENT NAME*
PARENT CELL*
ADDRESS (Street, City, State, Zip)*
SECOND PARENT CELL
SECOND PARENT CELL
EMERGENCY CONTACT INFORMATION:
In case of emergency, we will always try to contact parents first. Please provide an alternate emergency contact in the event we cannot reach you.
NAME*
RELATIONSHIP*
MAIN CONTACT NUMBER*
OTHER PHONE NUMBER
DOCTOR’S NAME*
PHONE NUMBER*
Please list all medical/environmental allergies, medications being taken, medical problems or other pertinent information. If none, please type NONE.*
Please list any food allergies. If none, please type NONE.*
Please answer YES or NO to the following, you may use Y and N.
CHICKEN POX*
APPENDIX REMOVED*
FAINTING SPELLS*
ASTHMA*
DIABETES*
HEART TROUBLE*
CONVULSIONS*
INSECT BITE ALLERGY*
If so, what insect
Please list any additional special conditions, restrictions, etc. you would like us to be aware of. If none, please type NONE*
INSURANCE INFORMATION:

If you DO NOT have insurance, please enter NONE if the each of the following insurance boxes.
INSURANCE CARRIER*
POLICY NUMBER*
CARDHOLDER NAME*
CARDHOLDER DOB*
PLEASE UPLOAD FRONT AND BACK OF INSURANCE CARD

Cancelof
I grant permission for any other adult, affiliated with First Baptist Church of Amarillo (over the age of 21), to seek necessary medical attention on my behalf. This permission is effective for one year from January 1, 2024 - December 31, 2025. I hereby release and forever discharge all other adults, affiliated with FBC Amarillo and of First Baptist Church, Amarillo, from all claims, demands, actions, or causes of action, past, present or future, arising out of any damage or injury while participating with FBC Amarillo. PLEASE CHECK YES ACKNOWLEDGING THIS STATEMENT.

YES
I give permission to publish pictures of my child in the Reporter or with the local media.*

YESNO
I give permission for my child to participate in field trips after being notified of the specific event.*

YESNO
I understand by entering my name below this constitutes as my electronic signature*

YES
Parent Signature*
Parent Email*
example@example.com
Second Email
example@example.com
Date*

MonthDayYear
Date
Should be Empty:

HEALTH RELEASE FORM 2024-2025

EMERGENCY CONTACT INFORMATION:

Please answer YES or NO to the following, you may use Y and N.

INSURANCE INFORMATION: