Kehillah High Registration Form

If yes, please describe

Participant Full Name*

First NameLast Name

NOTE: We require this health history in order to provide our staff with the information needed to better address any situations that may arise while in Israel. Providing inaccurate or incomplete information is to the detriment of the participant.

Does your child have any special learning needs or learn best in any specific types of educational settings?*

YesNo

If yes, please describe

Date

MonthDayYear

Does your child have any special behavioral or emotional issues we can help support?*

YesNo

If yes, please describe

Does your child have an IEP?*

YesNo

If yes, please describe

Does your child have any other special issues or needs?*

YesNo

Allergies - food, environment, medical, etc. *

Current medications taking:*

Dietary needs:*

Please indicate gluten free, dairy free, etc.

Anaphylactic Allergies*

YesNo

Asthma*

YesNo

Diabetes*

YesNo

Epilepsy/Seizures*

YesNo

Hearing Problems*

YesNo

Vision Problems*

YesNo

If you answered yes, to any of the above, please explain and list what accommodations we should consider.

Please list any medications your child is taking:*

Are there any other issues that are life threatening, require medication, or should be brought to our attention?*

This health history is correct as far as I know, and the person herein described has permission to engage in all prescribed activities except as noted by the examining physician and me. In the event that I cannot be reached in an emergency, I hereby give permission to the medical professional selected by the Pilgrimage staff to hospitalize, secure proper treatment, or order injection, anesthesia or surgery for the participant as named above.

Disclaimer: By signing this document you understand that reasonable accommodations are made in an effort to create an inclusive environment. Pilgrimage reserves the right to deny or revoke acceptance, in its sole discretion, at any point and additional costs/ fees may apply. Reasonable accommodations are not always possible in all experiences, environments, or circumstances. Contact us for details or with questions regarding your situation.

Parent/Guardian Full Name*

First NameLast Name

Parent/Guardian Signature*

Health History Questionnaire