FBC Spring Break Trip
Student's Name *
Student's Phone Number *
Students Date of Birth *
2019/2020 Grade Level *
Student's Gender *
Student Allergies? *
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. *
Any other concerns or needs the FBC staff should know concerning this student? *
Parent/Guardian Name *
Parent/Guardian Phone Number *
1) Emergency contact Info (other than yours) *
2) Emergency contact Info (other than yours) *
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