FBC HEALTH RELEASE

FBC HEALTH RELEASE

For 1st - 12th grade
STUDENT NAME
STUDENT CELL (Optional)
Please enter a valid phone number.Format: (000) 000-0000.
STUDENT BIRTH DATE

MonthDayYear
2 digit month, 2 digit day, 4 digit year
GRADE 2026-2027
GENDER
PARENT NAME
TSHIRT SIZE
PARENT CELL
Format: (000) 000-0000.
2ND PARENT NAME
2ND PARENT CELL
Please enter a valid phone number.Format: (000) 000-0000.
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.Format: (000) 000-0000.
OTHER PHONE NUMBER
Format: (000) 000-0000.
DOCTORS NAME
DOCTORS PHONE NUMBER
Format: (000) 000-0000.
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
2 digit month, 2 digit day, 4 digit yearDate
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 2026-August 2027. 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
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

FBC HEALTH RELEASE

EMERGENCY CONTACT INFORMATION:

INSURANCE INFORMATION: