Child's Name *
Child's Name
Pediatrician Information
Pediatrician's Name *
Pediatrician's Name
Pediatrician's Phone *
Pediatrician's Phone
Pediatrician's Address *
Pediatrician's Address
In Case of emergency Please contact (if parent cannot be reached)
Emergency Contact #1 *
Emergency Contact #1
Phone *
Phone
Alternate Phone
Alternate Phone
Emergency Contact #2 *
Emergency Contact #2
Phone *
Phone
Alternate Phone
Alternate Phone
Consent for Emergency Treatment
In case of medical emergency (G-d forbid) the school will call 911 or Hatzalah (ambulance). If swift medical attention is warranted, your child will be taken to the nearest hospital, together with his/her medical file. Parents will be immediately notified. Until parent is reached, a staff member or teacher will be in charge, and make all decisions about the care of the child. In all non-emergency situations, the parents will be contacted. If parents cannot be reached, we will contact your pediatrician and follow their instruction. In situations where the child must be taken home and you cannot be reached, we will contact the people you indicated as emergency contacts. By signing this form, you also consent to assume any fiscal responsibilities incurred by the school, in the course of your child’s medical emergency. I hereby authorize The Chabad City Gan Preschool to obtain necessary medical treatment for my child *
In case of medical emergency (G-d forbid) the school will call 911 or Hatzalah (ambulance). If swift medical attention is warranted, your child will be taken to the nearest hospital, together with his/her medical file. Parents will be immediately notified. Until parent is reached, a staff member or teacher will be in charge, and make all decisions about the care of the child. In all non-emergency situations, the parents will be contacted. If parents cannot be reached, we will contact your pediatrician and follow their instruction. In situations where the child must be taken home and you cannot be reached, we will contact the people you indicated as emergency contacts. By signing this form, you also consent to assume any fiscal responsibilities incurred by the school, in the course of your child’s medical emergency. I hereby authorize The Chabad City Gan Preschool to obtain necessary medical treatment for my child
(child name)
in accordance with the above-mentioned Emergency Policy for September 2015 - June 2016 academic year. *
in accordance with the above-mentioned Emergency Policy for September 2015 - June 2016 academic year.
(parent name)
Date *
Date
(today's date)
Trip Permission
I hereby give my child permission to go on all field trips (walking trips to the park, stores, library, other school, etc.) with the Chabad City Gan Preschool, during the September 2015 - June 2016 school year. *
I hereby give my child permission to go on all field trips (walking trips to the park, stores, library, other school, etc.) with the Chabad City Gan Preschool, during the September 2015 - June 2016 school year.
(parent name)
Date
Date
Picture Permission
I give permission for my child’s picture to be used for display and public relations purposes.
I give permission for my child’s picture to be used for display and public relations purposes.
(parent name)
Pickup Permssion
Please list the names of people who are authorized to pick up your child. We will only allow the individuals listed to pick up your child from school. If you ever have a situation that someone not listed will be doing pick up, please let us know.
Please list the names of people who are authorized to pick up your child. We will only allow the individuals listed to pick up your child from school. If you ever have a situation that someone not listed will be doing pick up, please let us know.
Is there anyone who may NOT pick up your child from school?
Is there anyone who may NOT pick up your child from school?