Medical, Media, and Liability Release

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. *
The staff at the TFP 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. *
TFP 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 TFP - Texas program. *	Yes No