Medical Information Form »

Child's Legal Name*

First Last

Physician

Child's Physician*

Physician's Phone

Physician's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Insurance

Insurance Company

Policy #

Copy of Insurance Card

Accepted file types: jpg, png, pdf, Max. file size: 512 MB.

Medical

Medical Conditions

Medication Currently being taken

Allergen

Signs of Exposure

Treatment

Allergen

Signs of Exposure

Treatment

Allergen

Signs of Exposure

Treatment

Consent

I hereby give permission, in the event of an emergency, for the director, the acting director, or the teacher at ALEF BET PRESCHOOL at CHABAD ISRAEL CENTER to take whatever steps necessary for the medical care of my child. I understand that in order for CHABAD ISRAEL CENTER to assume responsibility for my child, I, or the person(s) whom I have designated to drop off and pick up my child, must sign my child in at the time of arrival and out at the time of departure. I understand that, in response to the condition of my child, the following steps, and any others that may be called for, will be taken in the order most expedient, as the situation dictates: 1. The parent/guardian will be called. 2. If the parent/guardian is unavailable, the emergency contact person designated by the parent/guardian will be called. 3. The child’s physician will be called. 4. If these efforts are unsuccessful, the following steps will be taken (in the order deemed appropriate at the time): a) Another physician will be called. b) The child will be taken to the nearest emergency room accompanied by a staff member. c) An ambulance will be called to take the child to the nearest emergency room accompanied by a staff member. In the event of an emergency, if I cannot be reached, I hereby expressly give my consent for a CHABAD ISRAEL CENTER and/or ALEF BET PRESCHOOL staff member to transport my child to the nearest emergency facility and for the child’s physician and/or the emergency medical staff to administer any necessary medical treatment to my child as the situation may warrant. I give this express consent in the event CHABAD ISRAEL CENTER and/or ALEF BET PRESCHOOL is immediately unable to make contact with me because in an emergency situation waiting for the parent’s or guardian’s consent could jeopardize the health and welfare of my child. Parent/guardian agrees that it will hold CHABAD ISRAEL CENTER and ALEF BET PRESCHOOL harmless from any liability which may arise out of or in connection with this consent. Furthermore, Parent/guardian agrees to release and hold harmless CHABAD ISRAEL CENTER and ALEF BET PRESCHOOL, its agents, employees, and affiliates, from all liability, claims, and demands of whatever kind or nature, either in law or in equity, which arise from any harm or injury to my child, whether caused by the negligence of CHABAD ISRAEL CENTER and/or ALEF BET PRESCHOOL, its agents, employees or affiliates, or otherwise, to the full extent the release and hold harmless provisions of this paragraph are allowed by law. Parent/guardian agrees to reimburse CHABAD ISRAEL CENTER and/or ALEF BET PRESCHOOL for any medical expenses that arise while my child is in its care.*

I have read and agree with the Medical Policies

I hereby give permission, in the event of an emergency, for the director, the acting director, or the teacher at ALEF BET PRESCHOOL at CHABAD ISRAEL CENTER to take whatever steps necessary for the medical care of my child. I understand that in order for CHABAD ISRAEL CENTER to assume responsibility for my child, I, or the person(s) whom I have designated to drop off and pick up my child, must sign my child in at the time of arrival and out at the time of departure. I understand that, in response to the condition of my child, the following steps, and any others that may be called for, will be taken in the order most expedient, as the situation dictates:

1. The parent/guardian will be called.
2. If the parent/guardian is unavailable, the emergency contact person designated by the parent/guardian will be called.
3. The child’s physician will be called.
4. If these efforts are unsuccessful, the following steps will be taken (in the order deemed appropriate at the time):
a) Another physician will be called.
b) The child will be taken to the nearest emergency room accompanied by a staff member.
c) An ambulance will be called to take the child to the nearest emergency room accompanied by a staff member.

In the event of an emergency, if I cannot be reached, I hereby expressly give my consent for a CHABAD ISRAEL CENTER and/or ALEF BET PRESCHOOL staff member to transport my child to the nearest emergency facility and for the child’s physician and/or the emergency medical staff to administer any necessary medical treatment to my child as the situation may warrant. I give this express consent in the event CHABAD ISRAEL CENTER and/or ALEF BET PRESCHOOL is immediately unable to make contact with me because in an emergency situation waiting for the parent’s or guardian’s consent could jeopardize the health and welfare of my child.

Parent/guardian agrees that it will hold CHABAD ISRAEL CENTER and ALEF BET PRESCHOOL harmless from any liability which may arise out of or in connection with this consent. Furthermore, Parent/guardian agrees to release and hold harmless CHABAD ISRAEL CENTER and ALEF BET PRESCHOOL, its agents, employees, and affiliates, from all liability, claims, and demands of whatever kind or nature, either in law or in equity, which arise from any harm or injury to my child, whether caused by the negligence of CHABAD ISRAEL CENTER and/or ALEF BET PRESCHOOL, its agents, employees or affiliates, or otherwise, to the full extent the release and hold harmless provisions of this paragraph are allowed by law.

Parent/guardian agrees to reimburse CHABAD ISRAEL CENTER and/or ALEF BET PRESCHOOL for any medical expenses that arise while my child is in its care.

Signature*

Date*