CGI OD 2026 Medical Packet

MEDICAL INFORMATION 2026

Lubavitch on the Palisades Preschool, Tenafly Chabad Academy and Camp Gan Israel
Please complete forms for siblings separately.

Once submitted for the first child, you will be prompted to complete the form for additional children.
Please read our medical policies contained in the LPS/TCA/CGI document by clicking here.
Medical Policies Agreement*

I have read the Medical Policies in the Student Handbook
Select Program*
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Parent's Name*

First NameLast Name
Parent's Contact Phone*

Area CodePhone Number
Parent's E-mail*
Child's Physician*
Physician's Number*
Emergency Hospital Preference*
Insurance Company Name*
Policy Number*
Insurance Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

AUTHORIZATION TO CONTACT HEALTH PROVIDER

I authorize the non-public school/camp Nurse/Principal/Administrator to contact my primary health care provider on any questions related to my child's care.

ACKNOWLEDGEMENT OF MEDICATION ADMINISTRATION POLICY

I understand that the only medication that may be administered to my child is medication provided by me or my child’s physician/health provider. Any medications that I request to be administered must be stored in the school/camp office unless otherwise requested by me (ie. EpiPens may be kept in the classroom and stored by the teacher in the event that it is needed for immediate use).

I understand that prescription medication (ex. Antibiotics, EpiPen) must be in a container that is labeled by the pharmacist or physician, and can only be administered with a measuring device provided by me. I understand that school/camp personnel will only be able to administer medication if it is accompanied by an authorization form that specifies the medication, dose and directions for administration that is signed by me, the parent/guardian and the prescribing health care provider.

I understand that non-prescription medication (ex. Benadryl, Tylenol, Advil) must be in its original packaging and can only be administered with a measuring device provided by me. I understand that school/camp personnel will only be able to administer medication if it is accompanied by an authorization form that specifies the medication, dose and directions for administration that is signed by me, the parent/guardian and prescribing health care provider.

*Herbal remedies and nutritional supplements are not considered medications and are not to be administered in school/camp.
Authorization to Contact Health Provider*

I authorize the school/camp Nurse to contact my child's health provider
AUTHORIZATION FOR PEDIATRIC EMERGENCY
AND/OR SURGICAL TREATMENT

EXPLANATION: It is the firm hope that the authorization granted on this form will never need to be used. For the safety of the children, sound medical practice calls for such authorization. In emergency situations where for some reason the parent cannot be contacted immediately, this form will be used only when absolutely necessary and only after every attempt has been made to contact the parent. We find that doctors and hospitals refuse to give any treatment regardless of how minor, unless they have authorization from the parents. As you know, time can be a factor in being of assistance to your child where medical attention is needed, and this would assure us that no time would be lost in giving immediate treatment.

AUTHORIZATION: In the event that my child (or children) require medical care (and the determination thereof shall rest solely with Lubavitch on the Palisades), I hereby authorize the doctor and/or doctors and/or hospitals to which s/he (or they) may be brought, to take and perform all necessary procedures and render any indicated treatment, including the administration of an anesthesia, if needed, and the performance of an operation, if in the opinion of said doctor or doctors the same is necessary, while s/he (or they) is under the jurisdiction of Lubavitch on the Palisades Jurisdiction.

This authorization is given subject to and on the understanding that a sincere effort was made to contact parents, which effort was not successful, and on the further understanding that the doctor and/or doctors and/or hospitals to which s/he (or they) may be brought advices that delaying treatment until such time as a parent could be contacted could potentially pose a danger to my child and therefore cannot be delayed.
Authorization for Pediatric Emergency and/or Surgical Treatment Acknowledgement*

I acknowledge the Authorization for Pediatric Emergency and/or Surgical Treatment
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MEDICAL INFORMATION 2026