Student's Name

Date of Birth

Parent/Guardian's Name

Male Female (choose one)

Home Phone                     

Work Phone

Cell Phone                     

Other Phone

Address

Student E-mail Address

City, State, Zip Code

Parent E-mail Address

Alternative Emergency Contacts

Primary Emergency Contact

Secondary Emergency Contact

Home Phone                     

Work Phone

Home Phone                     

Work Phone

Address

Address

City, State, Zip Code

City, State, Zip Code

Medical Information

Hospital/Clinic Preference (if applicable)

Physician's Name (if applicable)

Phone Number

Insurance Company

Policy Number

Allergies/Special Health Considerations (please list any)

I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.

Parent's/Guardian's Name                                         Date

I give permission for my child to go on field trips. I release First Baptist Church - Lepanto, and individuals, from liability in case of accident during activities related to First Baptist Church - Lepanto, as long as normal safety procedures have been taken.

Parent's/Guardian's Name                                         Date