Child's Name |
Birth Date
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Medical and Developmental History |
Does your child have any medical, developmental or behavioral issue that we should know about? Describe:
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Please list any medication your child is taking on a regular basis: |
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Does your child have any allergies towards food or medication? |
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Does your child have need for an epi-pen? |
Yes No |
If yes, please provide a current epi-pen and written permission to administer to Hebrew School at the beginning of the school year |
Medical Emergencies |
I authorize the director or director's designee to seek appropriate medical care for my child, if necessary.
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