Health Information & Authorization - Form - Tree of Life Congregation

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Health Information & Authorization

Please verify reCaptcha before submitting the form.

* Student Name

* Parent(s) Name(s)

* Family Doctor

* Phone

* Insurance Company

* ID Number

* Current Medications (Name/Purpose/Side Effects)

If none, type "none."

* Allergies

Please list symptoms of allergic reactions (including any foods or medications) and remedy.
If none, type "none."

* My child has an Individualized Education Plan

Summary of IEP modifications/accommodations

* Other health/behavioral information

If none, type "none."

* I authorize provision of emergency medical services for my child in the event that I cannot be located.

YesNo

* I give permission for my child's picture to appear in Temple publications and media.

YesNo

* I give permission for my child's name to appear in the Religious School directory.

YesNo

Fri, April 19 2024 11 Nisan 5784

The Tree of Life Congregation is a proud member of the Union for Reform Judaism.

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