RWM Health Form 2026
Student Information
Student's Legal Name:
*
First Name
Last Name
Alberta Healthcare Number:
*
Does your child carry an EpiPen?
*
Yes
No
Please list any allergies. Include severity and instructions for support.
Please note any medical conditions. Include details of medical condition and instructions for support.
Parent/Guardian Information
Parent / Legal Guardian #1 (all legal parent/guardians must be listed):
*
First Name
Last Name
Phone No.
*
Format: (000) 000-0000.
Email
*
example@example.com
Parent / Legal Guardian #2 (all legal parent/guardians must be listed):
First Name
Last Name
Phone No.
Format: (000) 000-0000.
Email
example@example.com
Emergency Contact Information
We require two emergency contacts who are not listed above as legal parent/guardian.
Emergency Contact #1:
*
First Name
Last Name
Phone No.
*
Format: (000) 000-0000.
Emergency Contact #2:
*
First Name
Last Name
Phone No.
*
Format: (000) 000-0000.
Consent & Media Release
I hereby give permission for Foothills Academy Society to either record a lesson (recording is focused on the instructor) or have a Read/Write & Math staff member observe a lesson for training purposes only. Parents will be notified prior to any recording or in person observation.
*
Yes - I consent to my child's lesson being recorded or observed for the purposes of training only.
Yes - I consent to RECORDING ONLY
Yes - I consent to IN PERSON OBSERVATION ONLY
No - I do not consent to any recording of a lesson nor in person observation.
I hereby give permission for Foothills Academy Society to take pictures of my child for social media and advertising purposes. Your child's name will not be posted.
*
Yes - I consent to posting both on social media and for advertising.
Yes - I consent to posting on social media only.
Yes - I consent for advertising only.
No - I do not consent to pictures taken of my child for any purpose.
This form is submitted by a legal parent/guardian:
First Name
*
Last Name
*
Submit
Should be Empty: