Medical Form

Child's Name

Date of Birth

Medical and Developmental History

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

Does your child take any medications on a regular basis?

YesNo

Please list all medications

Does your child have any allergies towards food or medication?

YesNo

Please list all allergies

Does your child have need for an epi-pen?

YesNo

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

Medical Emergencies

Authorization

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

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

First Name

Last Name

Phone

Relationship to Student

Emergency Contact 2

First Name

Last Name

Phone

Relationship to Student

If parents cannot be reached and emergency medical advice is needed, permission is given to the Intown Hebrew School staff to phone my child's doctor:

Doctor

Phone

Address

Hospital Affiliation

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 IHS 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

Contact Information

Medical Form

Medical Form

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