Medical & Liability Form

I. Personal Information
Child's Name*
First Last
Birthdate*
MM slash DD slash YYYY
II. Medical Information
Please list any medical or other information we need to know (include any and all allergies, food allergies, medications or other special needs)
I agree to provide Headwaters my child's immunization records or appropriate exemption form where applicable.*
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.
- Yes
Upload your Immunization Record or Qualified Exemption here
Drop files here or

Max. file size: 512 MB.
III. Medical Insurance Information
(Please provide copy of insurance cards)
Insurance Carrier*
Policy Number*
Name of Policy Holder*
First Last
Copies of Insurance Cards
Drop files here or

Max. file size: 512 MB.
IV. Permission to Receive Medical Attention
Name of Person Giving Permission for 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.
First Last
V. Discipline
Name of Person Giving Permission for 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.
First Last
VI. Liability Release
Name of Person Giving 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.
First Last
Parent's Signature*
Date*
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/

I. Personal Information

II. Medical Information

III. Medical Insurance Information

IV. Permission to Receive Medical Attention

V. Discipline

VI. Liability Release