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FBC Spring Break Trip
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Student's Name
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Your answer
Email
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Student's Phone Number
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Your answer
Students Date of Birth
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Your answer
2019/2020 Grade Level
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7th
8th
9th
10th
11th
12th
Student's Gender
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Male
Female
Student Allergies?
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Yes
None
Is Yes, Please explain
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Does the Student take daily medications?
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Yes
No
If yes, which medication and how often?
Your answer
Does the student have a history of seizures?
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Yes
No
If so please explain.
Your answer
I give my permission for my student to receive medications listed below from FBC staff.
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Ibuprofen, Tylenol, Aspirin, Allergy Medicine, Pepto Bismal, Motion Sickness.
Please DO NOT give this student any medication.
Any other concerns or needs the FBC staff should know concerning this student?
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Your answer
Parent/Guardian Name
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Your answer
Parent/Guardian Phone Number
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Your answer
1) Emergency contact Info (other than yours)
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Your answer
2) Emergency contact Info (other than yours)
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Your answer
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