Hebrew School Emergency Form

Hebrew School Emergency Form

Please fill in the form below for each registered child.
Child's Full Name*

First NameLast Name
Parent 1 Full Name*

First NameLast Name
Parent 2 Full Name

First NameLast Name
Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*

Area CodePhone Number
Phone Number 2

Area CodePhone Number
E-mail*
Email 2
example@example.com
Emergency Contact*

First NameLast Name
Relationship to Child*
Phone Number*

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState

Zip Code
Primary Doctor*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Child's Insurance Information
Allergies and/or other Medical Conditions
“By submitting this form, I hereby give my consent, in the event of a medical emergency when I cannot be contacted, for Hebrew School staff to obtain whatever treatment may be deemed necessary for my child as named above."
Should be Empty: