Medical Form for all students - Chabad of Scottsdale Arizona

Contact Information
Child's Name*
First Name Last Name
Birth Date*

Month Day Year
Mother's Name*
First Name Last Name
Mother's Phone*
Father's Name*
First Name Last Name
Father's Phone*

Home address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

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?*

YesNo
If yes, please provide a current epi-pen and written permission to administer to JUDA 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
Name*
First Name Last Name
Home Phone*
Business Phone*
Street Address*
City*
Relationship to Student*
Emergency Contact 2
Name*
First Name Last Name
Home Phone*
Business Phone*
Street Address*
City*
Relationship to Student*
B. If parents cannot be reached and emergency medical advice is needed, permission is given to the JUDA staff to phone my child's doctor:
Doctor's Name*
Phone Number*
Street 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 JUDA 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*

Month Day Year
Father's Initials*
Date*

Month Day Year
Should be Empty:

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Contact Information

Medical and Developmental Form

Medical Emergencies

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