Child's Name  Birth Date  
 
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.
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  
Town   Town  
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   Town  
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  
 

BREITMAN FAMILY HEBREW SCHOOL AT THE CHABAD JEWISH CENTER