Kehilath Israel Synagogue

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Student 1 Information
Student Last Name
Student First Name
MI
GenderMF
Date of Birth
Time of Birth
Hebrew Name
Class DaysSun/Wed (3rd grade & up)Sunday only
Incoming School Grade
School Name
IEP / 504 plan / Intl Language Plan?YesNo
IEP/504 Explanation

Please note: we do NOT administer medication of any kind to a student
Allergies or Medical info / prescriptions taken on continuing basis?YesNo
Medical Needs Explanation

Student 2 Information
Student Last Name
Student First Name
MI
GenderMF
Date of Birth
Time of Birth
Hebrew Name
Class DaysSun/Wed (3rd grade & up)Sunday only
Incoming School Grade
School Name
IEP / 504 plan / Intl Language Plan?YesNo
IEP/504 Explanation

Please note: we do NOT administer medication of any kind to a student
Ongoing Medical Needs?YesNo
Medical Needs Explanation

Student 3 Information
Student Last Name
Student First Name
MI
GenderMF
Date of Birth
Time of Birth
Hebrew Name
Class DaysSun/Wed (3rd grade & up)Sunday only
Incoming School Grade
School Name
IEP / 504 plan / Intl Language Plan?YesNo
IEP/504 Explanation

Please note: we do NOT administer medication of any kind to a student
Ongoing Medical Needs?YesNo
Medical Needs Explanation

Student 4 Information
Student Last Name
Student First Name
MI
GenderMF
Date of Birth
Time of Birth
Hebrew Name
Class DaysSun/Wed (3rd grade & up)Sunday only
Incoming School Grade
School Name
IEP / 504 plan / Intl Language Plan?YesNo
IEP/504 Explanation

Please note: we do NOT administer medication of any kind to a student
Ongoing Medical Needs?YesNo
Medical Needs Explanation

Photography and Medical Release
Photo Release ConsentI hereby give consent for photographs, film, video or sound recordings to be taken of anyone in my family at Kehilath Israel Synagogue and they may be used in our publications, promotional materials, news releases, film, video, websites, and social media.
Medical Release ConsentIn the event of illness or injury to our child, we hereby authorize the staff of Kehilath Israel Synagogue to obtain the services of a licensed practitioner and , where required, to give consent for each treatment as may be necessary.
Doctor’s Name & Number
Preferred Hospital
Insurance Carrier
Group #
ID #
In the event a parent is unable to be reached please contact:
Emergency Contact Name & Phone
Relationship
Parent/Guardian Signature
Date

Contact