Emergency Health Information Form 26/27

Emergency Health Information Form

2026-2027 School Year
This form is to be completed for each child, as it becomes a part of the child's record. Please complete all information NO LATER than August 21st, 2026.
Child's Name

First NameLast Name
Grade
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent / Guardian Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent / Guardian Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent / Guardian 2 Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent / Guardian Work Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent / Guardian Work 2 Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent / Guardian Email
example@example.com
Parent / Guardian 2 Email
example@example.com
Pediatrician's Name
Pediatrician's Number
Please enter a valid phone number.Format: (000) 000-0000.

Grade 7 Immunization Requirements

Dear Parents,

In accordance with New Jersey state law, all students entering Grade 7 must have
the following booster vaccines: Tdap and Meningococcal.

If your child has not received the required vaccines, please schedule an
appointment with their doctor before the start of the upcoming school year. If the
vaccines have already been given, please send documentation to The Health
Office.

Documentation can be faxed to 732-493-2248 or emailed to
jcadenelli@hillelyeshiva.org and anoam@hillelyeshiva.org.

Please send all updated documentation to the health office by August 21, 2026.

Thank you,
The Hillel Yeshiva Health Office
Parent/Guardian Signature

Kindergarten Immunization Requirements

Dear Parents

In accordance with New Jersey state law all students entering
Kindergarten must have the following booster vaccines: Dtap, Polio,
and MMR.

If your child has not received the required vaccines, please schedule an
appointment with their doctor. If the vaccines have been given please
send documentation to The Health Office.

Documentation can be faxed to 732-493-2248 or emailed to
jcadenelli@hillelyeshiva.org and anoam@hillelyeshiva.org .

Please send all updated documentation to The Health Office by August 21,
2026.

Thank you,

The Hillel Yeshiva Health Office
Parent/Guardian Signature

Medications
MEDICATION ADMINISTRATION POLICY

Hillel Yeshiva
1025 Deal Rd. Ocean, NJ 07712

732.493.9300

Should it be necessary to administer medication during the school hours, these guidelines are to be followed:
- Written orders are to be provided to the school by the child’s physician. These should contain diagnosis, name of drug, dosage, times of administration, potential side effects.
- Medication must be brought to school by parent or guardian. Children cannot bring medication to school. This is for your child’s safety and the safety of other students.
- Medication must be brought to school in the original, appropriately labeled container.
- Signed parental permission to administer medication.
- This policy applies to all prescription and non- prescription medications.
- Forms are available in the health office.
Medication for Self Administration- inhalers, epi-pens:

Many children can independently manage their medical conditions (i.e. asthma, food allergies). If you wish to have your child carry medication for self- administration, please obtain the appropriate form from the nurse and have your child’s doctor fill the form out. Parent signature giving permission is also required on this form.

Our school physician has provided standing orders only for acetaminophen (Tylenol).
This medication will be given at the nurse’s discretion for headache or other pain without fever. Parent or guardian’s signature with dosage should be filled in on the emergency sheet in order for Tylenol to be administered.
No Tylenol will be administered without an updated emergency sheet.

Discarding of medication:

Medication not picked up by the last day of school will be discarded. We are unable to store medications in our office over the summer.
Tylenol is available for headaches or other pain without fever. If you wish your child to have Tylenol in these cases, please indicate the dosage below and sign your initials:
Number of Tablets Adult (325mg)
Initials of Parent/Guardian
Number of Tablets Junior/Chewable (160mg)
Initials of Parent/Guardian
Will your child be taking any medications while in school? Please see our Medication Administration Policy above.
Please list any other medical information you’d like the Health Office to know:
I state that all the above information is complete and correct. If there are any changes I will notify the school nurse in writing so that the record and care can be altered.

The school is administering medication under parental instructions as an accommodation to the parent and it does not assume any liability. I acknowledge that I have read the Hillel Yeshiva Medication Administration Policy.
Parent / Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Emergency Contacts
Please list three additional local numbers (including cellular) of people (NOT including parents) who will be available in an emergency to pick up a sick child or provide medical advice in the event a parent cannot be reached.
Name

First NameLast Name
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Child
Name

First NameLast Name
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Child
Name

First NameLast Name
Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Child
Please list siblings/grades:

Scoliosis Screening
Dear Parents of Incoming Students in Grades 5, 7, 9 and 11:

A screening program for scoliosis will take place every other year for every student between the ages of 10 and 18 as required by law. We will be screening students entering grades 5, 7, 9, and 11.

Scoliosis is defined as a condition of the spine in which the spine may curve to the left or right. It is most commonly found during the time of rapid growth and may progress if not treated. The purpose of the screening program is to recognize scoliosis in its earliest stages.

If you request for your child not to have the exam, you must submit a letter from your doctor that the scoliosis exam was done. Please provide this letter to the Health Office. If we do not receive written confirmation from your childs doctor, we will automatically screen you child for scoliosis.

Thank you for your cooperation.

The Hillel Yeshiva Health Office
Permission
Student Name

First NameLast Name
Grade
Parent / Guardian Signature

A physical exam is required for all ELC students annually. The Student Health History Form is to be completed by your child's medical provider. Please download the form below and bring this to your childs doctor to complete. Please bring completed form to Hillel Yeshiva Health Office or scan and email completed form to elcnurse@hillelyeshiva.org
Download & Print PDF
I understand the following

Download & Print PDF
Name of School District:
Name of Local School:

I/We acknowledge that we received and reviewed the Sudden Cardiac Death in Young Athletes pamphlet.
Student Signature:
Parent Signature:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Sports-Related Concussion and Head Injury Fact Sheet and Parent/Guardian Acknowledgement Form

A concussion is a traumatic brain injury that can be caused by a blow to the head or body that disrupts the normal functioning of the brain. This sudden movement can cause the brain to bounce around or twist in the skull, creating chemical changes in the brain and sometimes stretching and damaging brain cells, disrupting the way the brain normally functions. Concussions can cause significant and sustained neuropsychological impairment affecting balance, reading (tracking), problem solving, planning, memory, attention, concentration, and behavior. Concussions can range from mild to severe. Having a concussion increases the risk of sustaining another concussion. Second-impact syndrome may occur when a person sustains a second concussion while still experiencing symptoms of a previous concussion. It can lead to severe impairment and even death.

Requirements addressing sports-related concussions and head injuries for student athletes and cheerleaders
- All school districts, charter, and non-public schools that participate in interscholastic sports are required to distribute this educational fact sheet to all student athletes and cheerleaders and obtain a signed acknowledgment from each parent/guardian and student-athlete.
- Each school district, charter, and non-public school shall develop a written policy describing the prevention and treatment of sports-related concussion and other head injuries sustained by interscholastic student-athletes and cheerleaders.
- Any cheerleader or student-athlete who participates in an interscholastic sports program and is suspected of sustaining a concussion will be immediately removed from competition or practice. The student-athlete will not be allowed to return to competition or practice until they have written clearance from a physician trained in concussion treatment and have completed his/her district's graduated return-to-play protocol.
Quick Facts
- Most concussions do not involve loss of consciousness.
- You can sustain a concussion even if you do not hit your head.
- A blow elsewhere on the body can transmit an "impulsive" force to the brain and cause a concussion.
- Signs and symptoms of concussion can show up right after an injury or may not appear or be noticed until hours or days after the injury.
- Signs of Concussions (Observed by Coach, Athletic Trainer, Parent/Guardian/Caregiver, Teammate, and others)
Signs of Concussions (Observed by Coach, Athletic Trainer, Parent/Guardian/Caregiver, Teammate, and others)
- Appears dazed or stunned
- Forgets plays or demonstrates short term memory difficulties (e.g., unsure of game, opponent
- Exhibits difficulties with balance, coordination, concentration, and attention
- Answers questions slowly or inaccurately
- Is unable to recall events prior to or after the hit or fall
Symptoms of Concussion (Reported by Student-Athlete)
- Headache
- Nausea/vomiting
- Balance problems or dizziness
- Double vision or changes in vision - trouble reading
- Sensitivity to light/sound
- Feeling of sluggishness or fogginess - fatigue
- Difficulty with concentration, short term memory, and/or confusion
Dangerous Signs & Symptoms of a Concussion
- New onset of symptoms
- One pupil is larger than the other
- Drowsiness or inability to wake up
- A headache that gets worse and does not go away
- Slurred speech, weakness, numbness, or decreased coordination
- Repeated vomiting, nausea, or seizures (shaking or twitching)
- Unusual behavior, increased confusion, restlessness, or agitation
- Loss of consciousness (passed out/knocked out); even a brief loss of consciousness should be taken seriously.
What should a student-athlete do if they think they have a concussion?
- Do not hide it. Tell your athletic trainer, coach, school nurse, or parent/guardian.
- Report it. Do not return to competition or practice with symptoms of a concussion or head injury.
- Take time to recover. If you have a concussion, your brain needs time to heal. While your brain is healing you are much more likely to sustain a second concussion.
What can happen if a student-athlete continues to play with a concussion or returns to play too soon?
- Continuing to play with the signs and symptoms of a concussion leaves the student-athlete vulnerable to second impact syndrome.
- Second impact syndrome is when a student-athlete sustains a second concussion while still having symptoms from a previous concussion or head injury.
- Second impact syndrome can lead to severe impairment and even death in extreme cases.
Should there be any temporary academic accommodation made for student-athletes who have suffered a concussion?
- Most students will only need help through informal, academic adjustments as they recover from a concussion.
- Students may need to take rest breaks, spend fewer hours at school, be given extra time to complete assignments, as well as being offered other instructional strategies and classroom accommodations.
- Contact the school nurse if symptoms persist to discuss whether additional accommodations are necessary.
- To recover, cognitive rest is just as important as physical rest. Reading, texting, computer use and even watching movies can slow down recovery. Limit screen time during recovery.
Students who have sustained a concussion may not return to practice or competition until they receive written clearance from a physician trained in the evaluation and management of concussion and complete the graduated Six-step return to play protocol outlined by the CDC:

Step 1: Back to regular activities (such as school)
Athletes or cheerleaders are back to their regular activities (such as school).

Step 2: Light aerobic activity
Begin with light aerobic exercise only to increase an athlete's heart rate. This means about 5 to 10 minutes on an exercise bike, walking, or light jogging. No weightlifting at this point.

Step 3: Moderate activity
Continue with activities to increase an athlete's heart rate with body or head movement. This includes moderate jogging, brief running, moderate-intensity stationary biking, moderate-intensity weightlifting (less time and/or less weight from their typical routine).

Step 4: Heavy, non-contact activity
Add heavy non-contact physical activity, such as sprinting/running, high-intensity stationary biking, regular weightlifting routine, non-contact sport-specific drills (in 3 planes of movement).

Step 5: Practice & full contact
Athletes may return to practice and full contact (if appropriate for the sport) in controlled practice.

Step 6: Competition
Young athletes may return to competition.

For further information on Sports-Related Concussions and other Head Injuries, please visit:

CDC Heads Up
Student Athlete Name

First NameLast Name
Student Athlete Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent / Guardian Name

First NameLast Name
Parent / Guardian Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Download & Print PDF
Use and Misuse of Opioid Drugs Fact Sheet

Student-Athlete and Parent/Guardian Sign-Off

In accordance with N.J.S.A. 18A:40-41.10, public school districts, approved private schools for students with disabilities, and nonpublic schools participating in an interscholastic sports program must distribute this Opioid Use and Misuse Educational Fact Sheet to all student-athletes and cheerleaders. In addition, schools and districts must obtain a signed acknowledgement of receipt of the fact sheet from each student-athlete and cheerleader, and for students under age 18, the parent or guardian must also sign.

This sign-off sheet is due to the appropriate school personnel as determined by your district prior to the first official practice session of the spring 2018 athletic season (March 2, 2018, as determined by the New Jersey State Interscholastic Athletic Association) and annually thereafter prior to the student-athlete’s or cheerleader’s first official practice of the school year.
Name of School:
Name of School District:

I/We acknowledge that we received and reviewed the Educational Fact Sheet on the Use and Misuse of Opioid Drugs.

Student Signature:   StudentSignature*

Parent/Guardian Signature (also needed if student is under age 18):   ParentSignature*
Date:   Date*

Sport Physicals

Information Fact Sheets

All students on a school sponsored interscholastic team, grades 6 to 12, must hand in a completed Preparticipation Physical Evaluation Form (page 4 of enclosed packet), to the health office.

The PPE may only be completed by a licensed physician, Advanced Practice Nurse (APN) or Physician Assistant (PA) that has completed the student-athlete cardiac assessment professional development module.

The parent/guardian must complete the History Form (pages 1 and 2), bring them to the doctor's office along with the blank preparticipation physical evaluation physical exam form (page 3) and the preparticipation evaluation medical eligibility form (page 4).

The required PPE must be conducted within 365 days prior to the first official practice in an athletic season.

The licensed physician, APN or PA, who performs the physical examination must complete the Physical examination form (page 3), which will remain with the physician and the preparticipation physical evaluation medical eligibility form (page 4) needs to be completed by the physician and returned to the health office.

The licensed physician, APN or PA must also sign the certification statement on the Preparticipation Physical Evaluation Medical Eligibility Form attesting to the completion of the professional development module.

For students-athletes that had a medical examination completed more than 90 days prior to the first official practice in an athletic season, the Health History Update Questionnaire (HHQ) form must be completed and signed by the student's parent/guardian. The HHQ must be reviewed by the school nurse.

If you have any questions, please reach out to jcadenelli@hillelyeshiva.org or anoam@hillelyeshiva.org

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I understand the following

Download & Print PDF
I understand the following

Thank you for completing the Emergency Health Information Form

We are looking forward to another amazing year at Hillel Yeshiva!
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Emergency Health Information Form

Medications

Emergency Contacts

Scoliosis Screening