Medical Form Name of Student. (Complete a separate release for each additional student.) * List any allergies, handicaps, limiting health conditions, medications, reactions to medications of this student * Family doctor name and phone number. * Family dentist name and phone number. * Medical Insurance Provider and group number-policy number (if you have insurance. Students are permitted to attend without insurance, but the parents are financially responsible for medical treatment, if necessary. * The staff have my permission to obtain whatever medical care or diagnostic tests they deem necessary for the well-being of my children. * Yes No 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. * The program "Change for Tomorrow" has permission to use photos of my children on their website and publications * Yes No I hereby release and hold harmless the Spiritual Assembly of the Baha'is of Highland Village, TX, Inc. while my child participates in the Change for Tomorrow program. * Yes No