Medical Release Form – Temple Adath B'nai Israel

Temple Adath B'Nai Israel Medical Release Form

Name of Child

Child's Date of Birth

In case of injury or illness of a child at school, every effort will be made to contact the parent or guardian. The following instructions will remain in force unless revoked by parent or guardian:

Parent Name:

Cell:

Parent Name:

Cell:

If injury or illness is minor, give child first aid?

If injury or illness is serious and parent cannot be reached, do you wish for your personal physician or dentist to be contacted?

Name of Physician:

Phone:

Address:

Call an ambulance?

Name of Dentist:

Phone:

Address

In case you cannot be reached, who is the emergency contact?

Name:

Phone:

Name:

Phone:

Does your child have any allergies? (Please specify.)

In the event of a medical emergency, I authorize the staff to obtain emergency medical treatment for my child. I understand that I will be contacted immediately as will my physician.

Parent's Signature:

Date:

I accept this typed signature as my signature.

Yes No