Emergency Form

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HILLEL COMMUNITY DAY SCHOOL 2012-2013

EMERGENCY HEALTH INFORMATION FORM

Dear Parents,
We update our cumulative record files and Health Office Data annually. Please complete the health information below, sign and submit before the first day of school. This information is critical in that we be able to care for your child(ren) in an emergency and assures their file will be accurate.

Please provide the following characteristic information per child. This information is used for teachers to carry during field trips.

We will photograph your student/s on the first day of school for safety use for field trips.

1) Child's First Name:

Child's Last Name:

DOB (MM/DD/YYYY):

Grade:

Child's MD:

MD Phone:

Child's Dentist:

Dentist Phone:

Child's Orthodontist:

Orthordontist Phone:

Surgical/Medical:

Allergies:

Height:

Weight:

Hair Color:

Eye Color:

2) Child's First Name:

Child's Last Name:

DOB (MM/DD/YYYY):

Grade:

Child's MD:

MD Phone:

Child's Dentist:

Dentist Phone:

Child's Orthodontist:

Orthordontist Phone:

Surgical/Medical:

Allergies:

Height:

Weight:

Hair Color:

Eye Color:

3) Child's First Name:

Child's Last Name:

DOB (MM/DD/YYYY):

Grade:

Child's MD:

MD Phone:

Child's Dentist:

Dentist Phone:

Child's Orthodontist:

Orthordontist Phone:

Surgical/Medical:

Allergies:

Height:

Weight:

Hair Color:

Eye Color:

Title:

Father's First Name:

Father's Last Name:

Address:

City/State/Zip:

Employer/College Attending:

Home Phone:

Work Phone:

Cell Phone:

Pager:

Email:

Title:

Mother's First Name:

Mother's Last Name:

Address (if different):

City/State/Zip:

Employer/College Attending:

Home Phone:

Work Phone:

Cell Phone:

Pager:

Email:

If this pertains:

Parents Separated:

Parents Divorced:

Custody:

If the school cannot contact a parent, please name a friend or relative that is a licensed driver and has access to a vehicle who may pick up your child if they become ill and need to leave.

Contact Person #1:

Relationship:

Address:

Home:

Work:

Cell:

Pager:

Contact Person #2:

Relationship:

Address:

Home:

Work:

Cell:

Pager:

Although the recommendations of the parent will be respected as far as possible, I understand that in the final disposition of an emergency the school will act in the parent’s absence.

Signature:

Date (MM/DD/YYYY):

Please email this form to:

Enter the anti-spam code:

If you have a problem with this form or a suggestion, please fill out the "Contact Hillel Staff" form and select "Webmaster". Thank you.