• I. Personal Information

  • MM slash DD slash YYYY
  • II. Medical Information

  • We will need the required immunization records on file for your child for the appropriate grade they are in or a medical or religious exemption. You will find links to the required immunizations per grade at the bottom of this page as well as a link to the required medical exemption and an example of what's needed for a religious exemption. If you can upload the required document(s) now you can use the upload feature below, otherwise bring the documents to the office, bring to open house or send with your child on the first day of school.
  • Drop files here or
    Max. file size: 512 MB.
    • III. Medical Insurance Information

      (Please provide copy of insurance cards)
    • Drop files here or
      Max. file size: 512 MB.
      • IV. Permission to Receive Medical Attention

      • I give permission for my child to receive medication and emergency treatment in the event of illness or accident. I give the person(s) designated by Headwaters to be permission to make a decision concerning emergency treatment.
      • V. Discipline

      • I would like to inform the staff of Headwaters that I fully trust their judgments and decisions toward the well being of my child. I trust my son/daughter to adhere and abide by any and all rules set forth and decisions made by the staff. If my child does not, I expect them to be disciplined without the use of physical force as deemed necessary by the person(s) designated by Headwaters in accordance with the Parent/Child Handbook.
      • VI. Liability Release

      • I hereby release Headwaters, South River Baptist Church, their staff and volunteers of any and all liability in the event that my child is injured or becomes ill while in their care.
      • MM slash DD slash YYYY

      NC Immunizaton Information > https://immunize.nc.gov/schools/k-12.htm

      NC Medical Exemption Information > https://www.immunize.nc.gov/schools/ncexemptions.htm

      NC Religious Exemption Information > https://vaccineeducation.org/exemptions/nc-exempt/