Health Information & Authorization

* 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."

* IEP/504 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.

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

I would like to meet with Rabbi Carolan prior to the beginning of the year

Fri, April 26 2024 18 Nisan 5784