Sign In
Forgot Password
or Sign In With
Powered By
ShulCloud
Login
Home
About Us
Contact Us
Donate
ELC First Aid and Emergency Medical Care Consent Form
Please verify reCaptcha before submitting the form.
*
Child's Name
*
Child's Date of Birth
*
Parent Email
*
I authorize staff at Temple Beth Avodah who are trained in the basics of first aid/CPR to give my child first aid/CPR when appropriate.
Yes, I give permission for the above statement.
*
I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize Temple Beth Avodah to transport my child to the nearest medical facility and secure necessary medical treatment for my child.
Yes, I understand the above statement.
*
Child's Physician Name
*
Address
*
City, State, Zip
*
Child's Allegies
*
Chronic Health Conditions
Medical Emergency Contacts
Please note: ALL fields are required. Please list both parents, if applicable, and at least one other person. Please type in "N/A" for fields not used.
*
Medical Emergency Contact 1
*
Address
*
City, State, Zip
*
Relationship to Child
*
Home Phone Number
*
Cell Phone Number
*
Do you give permission for your child to be released to this person?
Please Select One
Yes
No
*
Medical Emergency Contact 2
*
Address
*
City, State, Zip
*
Relationship to Child
*
Home Phone Number
*
Cell Phone Number
*
Do you give permission for your child to be released to this person?
Please Select One
Yes
No
*
Medical Emergency Contact 3
*
Address
*
City, State, Zip
*
Relationship to Child
*
Home Phone Number
*
Cell Phone Number
*
Do you give permission for your child to be released to this person?
Please Select One
Yes
No
*
Medical Emergency Contact 4
*
Address
*
City, State, Zip
*
Relationship to Child
*
Home Phone Number
*
Cell Phone Number
*
Do you give permission for your child to be released to this person?
Please Select One
Yes
No
Health Insurance Information
*
Health Insurance Coverage
*
Policy Number
*
Parent 1 Name
*
Home Phone Number
*
Cell Phone Number
*
Work Phone Number
*
Parent 2 Name
*
Home Phone Number
*
Cell Phone Number
*
Work Phone Number
Signature & Date
*
By typing my name below and clicking "Submit" I hereby constitute that this is my electronic signature for legal purposes.
*
Date
Tue, April 23 2024 15 Nisan 5784