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 for "Last Name"

First Name*

Answer required for "First Name"

Middle Name*

Answer required for "Middle Name"

Date of Birth*

Answer required for "Date of Birth"

Gender*

Answer required for "Gender"

Grade*

Answer required for "Grade"

Parent/Guardian Information

Student resides with (check one)*

Answer required for "Student resides with (check one)"

Both Parents

Mother

Father

Other

Parent 1:

Last Name*

Answer required for "Last Name"

First Name*

Answer required for "First Name"

Middle Name*

Answer required for "Middle Name"

Relationship*

Answer required for "Relationship"

Cell Phone*

Answer required for "Cell Phone"

Work Phone*

Answer required for "Work Phone"

Parent 2:

Last Name*

Answer required for "Last Name"

First Name*

Answer required for "First Name"

Middle Name*

Answer required for "Middle Name"

Relationship*

Answer required for "Relationship"

Cell Phone*

Answer required for "Cell Phone"

Work Phone*

Answer required for "Work Phone"

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 for "Emergency Contact 1 Name:"

Emergency Contact 1 Relationship:*

Answer required for "Emergency Contact 1 Relationship:"

Emergency Contact 1 Cell Phone:*

Answer required for "Emergency Contact 1 Cell Phone:"

Emergency Contact 2 Home Phone:*

Answer required for "Emergency Contact 2 Home Phone:"

Emergency Contact 2 Name:*

Answer required for "Emergency Contact 2 Name:"

Emergency Contact 2 Relationship:*

Answer required for "Emergency Contact 2 Relationship:"

Emergency Contact 2 Cell Phone:*

Answer required for "Emergency Contact 2 Cell Phone:"

Emergency Contact 2 Home Phone*

Answer required for "Emergency Contact 2 Home Phone"

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

Answer required for "I give my child permission to take over the counter medication that is brought in by the parent with instructions"

Yes

My child may have first aid administered as deemed necessary*

Answer required for "My child may have first aid administered as deemed necessary"

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 for "Food allergies"

Medicine allergies*

Answer required for "Medicine allergies"

Bee sting or insect bite allergies*

Answer required for "Bee sting or insect bite allergies"

Other allergies*

Answer required for "Other allergies"

Does your student have:

Check all that apply

Answer required for "Does your student have:"

Asthma

Diabetes

Cancer

Seizures

Hearing Problems

Hearing Aids

Glasses

Contacts

Does your child have vision problems (be specific)

Answer required for "Does your child have vision problems (be specific)"

Does your child have heart problems (be specific)

Answer required for "Does your child have heart problems (be specific)"

Does your child have other medical problems (be specific)

Answer required for "Does your child have other medical problems (be specific)"

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

Answer required for "List all medications and dosages your child receives on a continual basis"

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 for "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."

Agree

Disagree

Please fix the highlighted areas below before submitting.

Emergency Care Information