Emergency Contact and Medical Information 2

Emergency Contact and Medical Information 2

Family form for School Offices Form Preview
  • Emergency Contact and Medical Information for a Child        2015-2016

  •  -
  • Alternative Emergency Contacts

  • Medical Information

  • I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that neither parent/guardian can be reached in the case of an emergency.


    I hereby give permission for my child(ren) listed above to participate in all Hillel Torah field trips during the 2015 - 2016 school year that the School decides are appropriate for my child(ren). I understand there will be prior notification of each trip and there may be an additional charge for each such trip. I understand and agree that the notice of each trip will typically be provided only by a note given to each child and the School will have responsibility for otherwise notifying me of specific trips. I hereby agree that: (1) if the School has given my child a notice to take home, (2) if required, the School receives from my child payment of the charge for a specific trip, and (3) the School has not, prior to the trip, received notice in writing from the undersigned or another parent or guardian of my child that permission for my child to attend that specific field trip had been withdrawn, the School can rely that the undersigned has agreed my child can attend that field trip.



    I give permission for my child’s picture to be used for publicity purposes by Hillel Torah North Suburban Day School. Hillel Torah may videotape or photograph students enrolled in our school, their siblings, and family members attending our programs and events. These photographs are for Hillel Torah publications, flyers, publicity efforts, brochures, web use, other electronic communications or video usage. All photos and videos are for Hillel Torah use only and become the sole property of Hillel Torah. I understand that parents are allowed to videotape classroom activities and events.



    I give permission for my contact information (home address, home phone number and email address(es)) to be provided and distributed to parents in my child’s grade (for convenience purposes such as for planning a child’s birthday party or bar/bat mitzvah).

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