Student Medical Information & Emergency / Pickup Contact Form

Student Medical Information & Emergency / Pickup Contact Form
Today's Date

MonthDayYear
Name of Parent Filling Up Form

First NameLast Name
Number of Students enrolled at RBA
MEDICAL INFORMATION
If needed, is the school able to administer the following OTC medications?
If needed, is the school able to administer the following OTC medications?
If needed, is the school able to administer the following OTC medications?
If needed, is the school able to administer the following OTC medications?
If needed, is the school able to administer the following OTC medications?
If needed, is the school able to administer the following OTC medications?
- Please list contacts in the order they should be notified
- FIRST EMERGENCY CONTACT
  
  First NameLast Name
- Relationship to Student
- Authorized to Pickup / Drop off?
- Address
  
  Street Address
  
  Street Address 2
  
  CityState / Province
  
  Postal / Zip Code
- Mobile Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Home/Work Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email
  example@example.com
- Receive emails from RBA?
- SECOND EMERGENCY CONTACT
  
  First NameLast Name
- Relationship to Student
- Authorized to Pickup / Drop off?
- Address
  
  Street Address
  
  Street Address 2
  
  CityState / Province
  
  Postal / Zip Code
- Mobile Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Home/Work Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email
  example@example.com
- Receive emails from RBA?
- THIRD EMERGENCY CONTACT
  
  First NameLast Name
- Relationship to Student
- Authorized to Pickup / Drop off?
- Address
  
  Street Address
  
  Street Address 2
  
  CityState / Province
  
  Postal / Zip Code
- Mobile Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Home/Work Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email
  example@example.com
- Receive emails from RBA?
- Add more?
- FOURTH EMERGENCY CONTACT
  
  First NameLast Name
- Relationship to Student
- Authorized to Pickup / Drop off?
- Address
  
  Street Address
  
  Street Address 2
  
  CityState / Province
  
  Postal / Zip Code
- Mobile Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Home/Work Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email
  example@example.com
- Receive emails from RBA?
- Add more?
- FIFTH EMERGENCY CONTACT
  
  First NameLast Name
- Relationship to Student
- Authorized to Pickup / Drop off?
- Address
  
  Street Address
  
  Street Address 2
  
  CityState / Province
  
  Postal / Zip Code
- Mobile Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Home/Work Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email
  example@example.com
- Receive emails from RBA?
- As the Parent/Guardian of the student(s) listed above, I give consent to have my student(s) receive first aid from faculty and staff of Regency Baptist Academy, receive first aid and medical treatment by emergency personnel, and to be transported to receive emergency care, if necessary. I understand I will be responsible for covering any charges including insurance. I give consent for the emergency contacts listed above to act on my behalf until I am available. I agree to review and update this information whenever a change occurs and at least once every year.
- Signature
- Should be Empty:

Student Medical Information & Emergency / Pickup Contact Form

MEDICAL INFORMATION