FBC Spring Break Trip
Student's Phone Number
Students Date of Birth
2019/2020 Grade Level
Is Yes, Please explain
Does the Student take daily medications?
If yes, which medication and how often?
Does the student have a history of seizures?
If so please explain.
I give my permission for my student to receive medications listed below from FBC staff.
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?
Parent/Guardian Phone Number
1) Emergency contact Info (other than yours)
2) Emergency contact Info (other than yours)
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