Child's Name Birth Date
Mother's Name   Father's Name  
Mother's Phone   Father's Phone  
Home address  
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


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 Chabad of Scottsdale Hebrew School  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