CHS Medical Form

Medical Form

1. Child Name*

First Last

Date of Birth*

Medical and Developmental History

Does your child have any medical, developmental or behavioral issue that we should know about? Describe:

Please list any medication your child is taking on a regular basis:

Does your child have any allergies towards food or medication?

Does your child have need for an epi-pen?

Yes
No

If yes, please provide a current epi-pen and written permission to administer to Hebrew School at the beginning of the school year

Medical Emergencies

I authorize the director or director's designee to seek appropriate medical care for my child, if necessary.

Emergency Contact

In case of emergency, when neither parent can be reached, give name of who will take responsibility for your child:

Name*

First Last

Address*

Street Address City State ZIP Code

Cell*

Home Phone

Work Phone

Relationship to child*

Medical Agreement

In case of medical emergency requiring immediate emergency care, I authorize the paramedics to take my child to the nearest hospital if necessary. It is understood that I will hold Chabad Hebrew School of Monmouth County harmless for the nature and outcome of any emergency medical treatment. It is also understood that I leave the decision of what constitutes an emergency to the sole direction of the staff (please sign)

Mother's Initials*