2019 Kenly Original Free Will Baptist Parent/Guardian Release Form
Name of Student: *
Your answer
Age of Student: *
Your answer
Student's Physical Address: *
Your answer
Student's Mailing Address: *
Your answer
Parent/Guardian Name(s): *
Your answer
Parent/Guardian Contact Numbers and Relationship: *
Your answer
Parent/Guardian Physical Address: *
Your answer
Parent/Guardian Mailing Address: *
Your answer
Student's Emergency Contact: *
Your answer
Student's Emergency Contact's Phone Number: *
Your answer
Does your student have any allergies? If so, please list all. If not, please put N/A. *
Your answer
Name of student's Health Insurance Company and their Policy Number: *
Your answer
Student's primary care doctor and their phone number: *
Your answer
Is your student on any medications? If so, please list all medications. If not, please put N/A. *
Your answer
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. *
Your answer
Please list any other medical notes/concerns we should be aware of.
Your answer
Any additional notes you feel we should know or be aware about regarding your student:
Your answer
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. *
Your answer
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. *
Your answer
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