Congregation Beth Sholom Religious School
2008 - 2009
Health Form
Parents, please complete a health form for each child registered.
Students Name______________________________ Phone No.__________________________
Pediatrician Name and Location_____________________________ Phone No.______________
Parent/Guardian Name(s)_________________________________________________________
Cell Phone or Pager No.__________________________________________________________
If parents are not available in an emergency, please notify_______________________________
Relationship______________________ Home Phone_______________ Cell________________
Does your child have any dietary restrictions or allergies?________________________________
Date of last Tetanus shot:______________________
Will your child need to bring and/or take any medication while at Religious School?
If yes, please explain _____________________________________________________________
______________________________________________________________________________
(For any child needing medication or special medical consideration on a regular basis while at
Religious School, we will need a note of explanation so that we can meet your child’s needs).
The above information is correct to the best of my knowledge and I give my child permission to
engage in all activities. I hereby authorize the calling in of a physician and/or the providing of
necessary medical services at my expense should an emergency arise.
____________________________________________________ Date _____________________
Parent Signature