2024 Student Medical Records and Parental Permission Form

Student Name

Gender

Male Female

Student Cell Phone

Address

Student's Birth Date

Graduation Year

School Student Attends

Student Email Address

If a visitor, invited by:

Parent/Guardian Information

Parent/Guardian Name #1

Primary Parent Phone Number

This is the FIRST number we will try in the case of an emergency.

Parent/Guardian #1 Cell Phone Number

Parent/Guardian #2

Parent/Guardian #2 Cell Phone Number

Parent #1 Email

This address will receive a confirmation email

Parent #2 Email

Emergency Contact Info

Emergency Contact

Emergency Contact Phone (to be used if parents/guardians are not able to be reached.)

Emergency Contact Relationship to student

Health Information

Student's Doctor

Doctor's Phone Number

Other Medical Conditions

Please list any pertinent health conditions that the student has. Include the normal treatment required.

Name and dosage of any medication that must be taken.

Date of last tetanus shot

Allergies Yes No

If yes, please explain:

Any activity restrictions? Yes No

If yes, please explain:

Health Insurance Information

Do you have health insurance?

Yes No

Health Insurance Company Name

Insurance Policy Number

Policy Holder's Name

Place of Employment

Medical Release

In the event that I cannot be reached in an emergency, I hereby give my permission to the physician or dentist selected by the church leadership to hospitalize, to secure proper treatment, and/or order an injection, anesthesia, or surgery for my son or daughter as deemed necessary

Yes, I have read the statement and agree.

Liability Release

Every activity sponsored by this church is carefully planned and adequately supervised by mature adults. However, even with the best of planning and precaution, unforeseen events can occur. By agreeing to this form, the parent or guardian agrees to assume and accept all risks and hazards inherent in church-related social activities. They also agree not to hold this church or its employees or volunteer assistants liable for damages, losses, or injuries to the person or property undersigned. The parent or guardian understands that they are agreeing for the minor listed on this form.

Yes, I have read the statement and agree.

Permission for Social Media

I grant Faith Bible Church permission to publish pictures of my child in FBC publications. No identifying information will be used.

Yes, I grant persmission. No, I do not grant permission.

E-signature of parent/guardian

Date

2024 Student Medical Records and Parental Permission Form

Description

Please Fix the Following