"Taste of EHS" Registration and Health Form
Please complete prior to your child's visit so that we can best serve their needs while they are here on campus. Please complete a separate form for each participant.
Email
*
example@example.com
Program Registration Information
Select which day(s) your child will be attending. (Please check all that apply.)
*
Wednesday, January 28, 2026 (12:15—3:00 PM)
Wednesday, February 4, 2026 (11:45 AM—3:00 PM)
Will your child stay for the optional after-school STEM activity, ending at 4:15 PM?
*
Yes, my child will stay for the STEM activity ending at 4:15 PM.
No, my child will not stay for the STEM activity.
Is your child registered for J Adventure at the JCC that day?
*
Yes, my child will be attending J Adventure at the JCC that day. I understand that an EHS staff member will walk my child to and from the "Taste of EHS" program.
No, my child does not participate in J Adventure. I will drop off and pick up my child at EHS.
I'm not sure. Please contact me.
EHS will provide pizza lunch at no cost to participants. Pizza is homemade in the school's Kosher, nut-free kitchen. If you do not want your child to eat pizza lunch, please provide a bag lunch (please no nuts and no meat).
*
Yes, thank you for providing my child with pizza lunch.
I do not want my child to have the EHS pizza lunch. I will provide a bag lunch for my child.
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Contact Information
Student's Name
*
First Name
Last Name
Student's Date of Birth
*
-
Month
-
Day
Year
Date
Student's Current Grade
*
Please Select
Pre-K
Kindergarten
Grade 1
Grade 2
Grade 3
Grade 4
Gender
*
Male
Female
Non-Binary
Preferred Pronouns
*
Please Select
She/Her
He/Him
They/Them
Other
Parent/Guardian Name - 1
*
First Name
Last Name
Parent/Guardian Email -1
*
example@example.com
Parent/Guardian Phone - 1
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Name - 2
First Name
Last Name
Parent/Guardian Name - 2
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email - 2
example@example.com
Student's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Medical Information
Please indicate any conditions that apply. If any conditions apply, please describe in the space provided below.Please also note that if any of these conditions apply, you MUST speak to the school nurse prior to the visit.
Conditions (please check all that apply)
*
Allergies
Asthma
ADHD
Behavioral
Bladder Condition
Bleeding Condition
Bowel Condition
Cerebal Palsy
Cystic Fibrosis
Dental Concerns
Diabetes Type 1
Diabetes Type 2
Head Injury
Hearing/Vision Issues
Lead Poisoning
Heart Condition
Muscle Condition
Seizures
Sickle Cell
Surgeries
None of these apply
If any of the above are checked, please describe below:
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Health Insurance Company and Policy Number
*
Name of Child's Physician
*
Physician Contact Information
*
Date of Most Recent Physical Exam
*
-
Month
-
Day
Year
Date
Medications
List any medications taken, including epi-pen/seizure medication. PLEASE NOTE: Any medications that need to be taken during the school day will require a physician's order dropped off at school before it can be administered.
Medication Name and Dosage
Please attach a copy of most recent physical.
*
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Emergency Medical Authorization
In the event I cannot be reached, I authorize Epstein Hillel to provide emergency treatment to my child and transport them to the nearest medical facility in the case of emergency.
*
Yes
No
Photo Release
I authorize Epstein Hillel School and those acting within its permission and authority to use photographs or other visual images of my child for school-related purposes, including publicity, marketing, social media, promotional and/or educational purposes, including publications, presentations or broadcast via newspaper, internet or other media sources. By checking YES, I hereby release the School and those acting within its permission and authority from any claims, causes of action or liabilities arising from any exercise of the authority granted above. I understand that I will not have the right to inspect those images prior to their use by the school, that such images may be used on more than one occasion, and that I will not be entitled to receive any compensation for the use of such images.
Pictures of my child...
*
Can be used for school-related purposes, including publicity, marketing, social media, promotional and/or camp purposes, including publications, presentations or broadcast via newspaper, internet or other media sources.
Please do not take pictures of my child during the school day.
Signature
By signing this, you agree that all information is true.
Signature
*
Submit
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