|
Your account number (10-digit phone number)
* |
|
|
Are any members of your group under the age of 18? If yes, please complete the medical release information for each person under the age of 18.
|
|
|
List the name of the first person under age 18.
|
|
|
List the age of the first person under age 18.
|
|
|
List any allergies, handicaps, limiting health conditions, medications, reactions to medications of the first person under age 18.
|
|
|
List the name of the second person under age 18.
|
|
|
List the age of the second person under age 18.
|
|
|
List any allergies, handicaps, limiting health conditions, medications, reactions to medications of the second person under age 18.
|
|
|
List the name of the third person under age 18.
|
|
|
List the age of the third person under age 18.
|
|
|
List any allergies, handicaps, limiting health conditions, medications, reactions to medications of the third person under age 18.
|
|
|
List the name of the fourth person under age 18.
|
|
|
List the age of the fourth person under age 18.
|
|
|
List any allergies, handicaps, limiting health conditions, medications, reactions to medications of the fourth person under age 18.
|
|
|
List the NAME, AGE, and any allergies, handicaps, limiting health conditions, medications, reactions to medications of additional persons under age 18.
|
|
|
The staff at the Texas Baha'i School have my permission to obtain whatever medical care or diagnostic tests they deem necessary for the well-being of my children, named above, while they are attending the Texas Baha'i School. Parent/Guardian can be located at the following address:
|
|
|
Contact telephone number and/or cell phone number.
|
|
|
Emergency contact person and phone number.
|
|
|
Family doctor name and phone number.
|
|
|
Family dentist name and phone number.
|
|
|
Medical Insurance Provider and group number-policy number.
|
|
|
By providing the last four digits of your telephone number, you are signing this agreement. Please type in the last four digits of your telephone number here; this will be accepted as your signature.
* |
|
|
|
