YDH Emergency Procedure Form
Family Name:
Phone
Address:
Email (Mother)
Email (Father)
Student Name:
Date of Birth:
Grade
IN CASE OF EMERGENCY, ILLNESS, OR ACCIDENT TO THE CHILD NAMED ABOVE, THE SCHOOL IS AUTHORIZED TO PROCEED AS INDICATED BELOW (NUMBER EACH ITEM IN ORDER OF DESIRED ACTION). YOUR CELL NUMBER COULD SAVE A LIFE.
1
Contact
Mother
Father
Mother's Phone
Father's Phone
Physician's Name:
Physician's Phone #:
Physician's Address
Medication Name:
Condition for which the drug is administered:
Instructions for Medication Administration:
By checking this box, you are giving Yeshiva Derech HaTorah permission to administer Acetaminophen to your child.
ALLERGIES, PHYSICAL LIMITATIONS, OR MEDCAL INFORMATION SCHOOL SHOULD BE AWARE OF:
Parent/Guardian Authorization Signature:
Clear
Consent is hereby given to allow my child to go by vehicle or otherwise on trips away from school, and the school will provide supervision for such occasion.
Date
Preview Submission
SUBMIT MEDICATION FORM
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