FBC HEALTH RELEASE

FBC HEALTH RELEASE

For 1st - 12th grade
STUDENT NAME*
STUDENT CELL (Optional)
Please enter a valid phone number.
STUDENT BIRTH DATE*

MonthDayYear
GRADE 2025-2026*
GENDER*
PARENT NAME*
PARENT CELL*
2ND PARENT NAME
2ND PARENT CELL
Please enter a valid phone number.
PARENT EMAIL*
example@example.com
ADDITIONAL EMAIL
example@example.com
Street Address*
City*
State*
Zip Code*
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*
Please enter a valid phone number.
OTHER PHONE NUMBER
DOCTORS NAME*
DOCTORS PHONE NUMBER*
Please list all medical/environmental allergies, medications being taken, medical problems, special conditions, restrictions or other pertinent information you would like us to be aware of. If none, please type NONE*
PLEASE LIST ANY FOOD ALLERGIES. If none, please type NONE*
INSURANCE INFORMATION:
Do you have medical insurance*
Please provide information below, and a copy of your insurance card.
INSURANCE CARRIER*
POLICY NUMBER*
CARDHOLDER NAME*
CARDHOLDER DATE OF BIRTH*

MonthDayYear
Date
PLEASE UPLOAD A COPY OF THE FRONT OF YOUR INSURANCE CARD*

Cancelof
PLEASE UPLOAD A COPY OF THE BACK OF YOUR 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 August 2025- August 2026. 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. I give permission to publish pictures of my child in church media or publications. I give permission for my child to participate in field trips after being notified of the specific event.
Parent Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

FBC HEALTH RELEASE

EMERGENCY CONTACT INFORMATION:

INSURANCE INFORMATION: