January 2024 – December 2024
Please fill out for one child at a time, please do not put multiple children on one submission.

We must have an individual form on file for each child.

Thank you.
Gender *
In case of emergency, we will always try to contact parents first. Please provide an alternate emergency contact in the event we cannot reach you.
Chicken Pox *
Appendix removed *
Fainting spells *
Convulsions *
Asthma *
Diabetes *
Heart trouble *
Insect bite allergy? *
I would like to upload an image of my student's insurance card *

Should you choose not to upload an image of your insurance card, please fill out the required insurace information below.



I grant permission for any other adult, affiliated with First Baptist Church of Amarillo (over the age of 21), to seek necessary medical attention on my behalf. This permission is effective for one year from
January 1, 2024 - December 31, 2024. I hereby release and forever discharge all other adults, affiliated with FBC Amarillo and of First Baptist Church, Amarillo, from all claims, demands, actions, or causes
of action, past, present or future, arising out of any damage or injury while participating with
FBC Amarillo.

I give permission to publish pictures of my child in the Reporter or with the local media.

I give permission for my child to participate in field trips after being notified of the specific event.


I understand that entering my name below constitutes as my electronic signature. *