Child's Name Birth Date Medical and Developmental Form 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. A. In case of emergency, when neither parent can be reached, give names of two people who will take responsibility for your child: Emergency Contact 1 Emergency Contact 2 Name Name Home Phone Home Phone Business Phone Business Phone Address Address City City Relationship to Student Relationship to Student B. If parents cannot be reached and emergency medical advice is needed, permission is given to the Hebrew School staff to phone my child's doctor: Doctor Phone Address City Hospital Affiliation C. 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 BFHS 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 Date Father's Initials Date This page uses 128 bit SSL encryption to keep your data secure.
