2019 Kenly Original Free Will Baptist Parent/Guardian Release Form
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Name of Student: *
Age of Student: *
Student's Physical Address: *
Student's Mailing Address: *
Parent/Guardian Name(s): *
Parent/Guardian Contact Numbers and Relationship: *
Parent/Guardian Physical Address: *
Parent/Guardian Mailing Address: *
Student's Emergency Contact: *
Student's Emergency Contact's Phone Number: *
Does your student have any allergies? If so, please list all. If not, please put N/A. *
Name of student's Health Insurance Company and their Policy Number: *
Student's primary care doctor and their phone number: *
Is your student on any medications? If so, please list all medications. If not, please put N/A. *
Are there any other adults or family members who are NOT authorized to pick up your student? If so, please list their name and their relationship to your student (if applicable). If this does not apply to you, please put N/A. *
Please list any other medical notes/concerns we should be aware of.
Any additional notes you feel we should know or be aware about regarding your student:
I understand that as the parent/legal guardian of my student only I can administer medication to my student unless deemed necessary under the judgement of a recognized medical facility under the general or special supervision of a licensed physician. By checking "I understand," you are consenting to your understanding and agreement of this statement. *
I grant permission for KOFWB to use and record pictures and videos of my student without payment or any other consideration. I understand that this authorization extends to all languages, media, formats, and markets now known or herether devised. This authorization shall continue unless I otherwise revoke said authorization in writing. By checking "I undersand," you are consenting to your understanding and agreement of this statement. *
I hereby declare that I am who I say I am when completing this Release Form. I am agreeing that I am the Parent/Guardian of the student I am signing this Release Form for. To agree to this statement, please type your name below as a form of an electronic signature, including today's date. *
As the parent/legal guardian of my student, I hereby declare that the above information is accurate and up to date. Please type your name as an electronic signature along with today's date to confirm this statement. *
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