* Required Information

Father's Information

Mother's Information

Guardian's Information
In case of accident or illness and I can not be reached, who should be notified?
Names and addresses of emergency contacts

Persons who can pick up my child (ren) from school. I will update this list as needed.
Names and addresses of person(s) authorized to pickup child (ren) from Joshua Christian Academy:

MEDICATIONS: (include name of medication, dosage, time of administrations, reason for medication, physician’s name)

I authorize Joshua Christian Academy or any of its agents to dispense medicine to my child, , if needed. This includes Tylenol, Motrin, Tums, Mylanta, Pepto Bismol, Neosporin and other basic over-the-counter medications including the use of alcohol, peroxide, witch hazel, first aid cream, etc.

I understand that any medication must be given to a school administrator and that my child may not have it in his/her possession. I further understand that I must provide written, signed instructions as to when and how the medication should be administered. I agree to hold Joshua Christian Academy and its representatives harmless for any liability to my child because of any claims on behalf of my child against Joshua Christian Academy or any representative thereof because of any injury or alleged injury to my child which results from dispensing of said medication unless said injury was willful or negligent. Should leg al action, for any reason, be taken against Joshua Christian Academy or any employee or representative thereof, on my child’s behalf and the school or its representative not be found at fault, I agree to pay all legal fees, such as attorney fees, court cos t, damages or other costs that may arrive from this issue that Joshua Christian Academy or its representative should incur to defend itself against such action.