Emergency Care Information

Please complete the form below. Required fields marked with an asterisk *

EMERGENCY CARE INFORMATION

In case of an emergency, the school will contact 911. Every attempt will be made to contact a parent, or a designated emergency contact.

Student Information

Last Name*

Answer Required

First Name*

Answer Required

Middle Name*

Answer Required

Date of Birth*

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Gender*

Answer Required

Grade*

Answer Required

Parent/Guardian Information

Student resides with (check one)*

Answer Required

Both Parents

Mother

Father

Other

Parent 1:

Last Name*

Answer Required

First Name*

Answer Required

Middle Name*

Answer Required

Relationship*

Answer Required

Cell Phone*

Answer Required

Work Phone*

Answer Required

Parent 2:

Last Name*

Answer Required

First Name*

Answer Required

Middle Name*

Answer Required

Relationship*

Answer Required

Cell Phone*

Answer Required

Work Phone*

Answer Required

If you are unable to reach me during any emergency, you are authorized to contact, and if necessary, release my child to any of the following:

Emergency Contact 1 Name:*

Answer Required

Emergency Contact 1 Relationship:*

Answer Required

Emergency Contact 1 Cell Phone:*

Answer Required

Emergency Contact 2 Home Phone:*

Answer Required

Emergency Contact 2 Name:*

Answer Required

Emergency Contact 2 Relationship:*

Answer Required

Emergency Contact 2 Cell Phone:*

Answer Required

Emergency Contact 2 Home Phone*

Answer Required

I give my child permission to take over the counter medication that is brought in by the parent with instructions*

Answer Required

Yes

My child may have first aid administered as deemed necessary*

Answer Required

Yes

Current Health Conditions

Below check any current health condition that may require attention during the school day:

Allergies (be specific) - list reaction and treatment

Food allergies*

Answer Required

Medicine allergies*

Answer Required

Bee sting or insect bite allergies*

Answer Required

Other allergies*

Answer Required

Does your student have:

Check all that apply

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Asthma

Diabetes

Cancer

Seizures

Hearing Problems

Hearing Aids

Glasses

Contacts

Does your child have vision problems (be specific)

Answer Required

Does your child have heart problems (be specific)

Answer Required

Does your child have other medical problems (be specific)

Answer Required

List all medications and dosages your child receives on a continual basis

Answer Required

By clicking accept, I hereby authorize The Jewish Academy of Orlando located at 851 N. Maitland Avenue, Maitland, Florida, by and through its designated agents, employees, and/or volunteers, to administer medications and/or first aid to my child. In consideration for Jewish Academy of Orlando administering medicine and first aid to my child as referred to herein, I hereby agree to indemnify and hold harmless Jewish Academy of Orlando, it’s officers, directors, agents, employees, and volunteers, from any and all liability that may arise out of the administering of medicine and first aid to my child, the following of the written instructions that I have provided herewith, or the direct or indirect consequences of either. Although the above recommendation of the parent will be respected as much as possible, I understand that in the final disposition of any emergency case, the judgement of the school will prevail. Anytime the above information changes, I will notify in writing. In the event my child needs to be transported to the hospital for emergency treatment, I will be responsible for all incurring costs.*

Answer Required

Agree

Disagree

Please fix the highlighted areas below before submitting.

Emergency Care Information