ELC First Aid and Emergency Medical Care Consent Form - 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 OneYesNo

* 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 OneYesNo

* 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 OneYesNo

* 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 OneYesNo

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