5005 I-40 West

Amarillo, Texas 79016     Office – 352-5620

(To be kept in teacher’s possession when on field trips)

Student’s Name: ________________________Home Phone: ____________________

Home Address: ____________________City:_______________State:_____Zip:_____


E-Mail Address:______________________Grade: ____________ (Pre-K 3’s AM) or Pre-K 4’s PM )  

Father’s Name: _____________________ Business Phone: _____________________

                                                 Cell Phone: _________________________

Mother’s Name: ____________________ Business Phone: _____________________

                                                Cell Phone: _________________________

Family Physician: ___________________ Physician Phone: ____________________

TO WHOM IT MAY CONCERN:  I do here with authorize the treatment by a licensed medical physician of the above named minor in the event of a medical emergency which, in the opinion of the attending physician, may endanger his or her life, cause disfigurement, physical impairment, or undue discomfort if delayed.  This authority is granted only after a reasonable effort has been made to reach me.

Release is intended for 2015-2016 school year.

This release form is completed and signed of my own free will for the sole purpose of authorizing medical treatment under emergency circumstances in my absence.

Signed: __________________ Relationship: ___________________ Date: ___________

Specific medical allergies, chronic illness, or other conditions affecting student: _______


Specific medication currently being taken by student: ____________________________

Medical Insurance Company: _______________________________________________

Medical Insurance Policy #: ________________________________________________

Other contact in Case of Emergency: _____________________ Phone #: ____________                schoolregistrationmedicalform