School Permissions Slip Form - Westbury Christian School

Which visiting school does your child attend? *

Parent Name: *

First

Last

Student Name: *

First

Last

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Emergency Contact Name: *

Emergency Contact Phone Number: *

Emergency Contact Relationship: *

Doctor:

Doctor Phone Number:

Doctor Address:

Address Line 1

Address Line 2

City

State

Zip Code

Preferred Hospital:

Hospital Phone Number:

Hospital Address:

Address Line 1

Address Line 2

City

State

Zip Code

Insurance Plan:

ID Number:

Subscriber Name:

On Insurance Card

Special conditions, disabilities, allergies, food allergies, or medical information:

If none, please put NA

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Parent Signature (please type) *

Release: I/we have given instructions required above, and I/we release and save harmless the school and any and all of its employees and any and all of the adult chaperones from and all liability for and all harm, injuries, and damages suffered by my/our son/daughter which occurs during this visit and arising either out of the acts of third parties or as a result of the condition of premises not under the control of the school and waive any claims against them.

Date: *

Student Name: *

I/we give permissions for _____________________________________ to be transported by ambulance and/or to be treated in the event of a medical emergency.

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I am interested in the following classes (please check all that apply):

Accounting/Business
Anatomy/Physiology
Biology
Calculus
Chemistry
Computer Science
Engineering/Robotics/Coding
Government/Economics
Photography/Fashion Design
Physics
Spanish/French
Theater

I am interested in the following Athletics Programs (please check all that apply):

Basketball
Baseball
Cheer
Cross Country
Golf
Football
Soccer
Softball
Tennis
Track and Field
Volleyball
None of the above

I am interested in the following Fine Arts Programs (please check all that apply): (copy)

Art
Band
Choir
Drum Line
Theater
None of the above

What clubs or student organizations are you interested in ?

The thing I am looking most forward to as a freshman in high school is:

Please list any WCS students or families that your student knows:

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I am interested in receiving further information about WCS and my student's visit to WCS from the Admissions Office: *

Email *

Permission Slip

10420 Hillcroft Street,
Houston, Texas 77096