Emergency Information Form

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Step 4

Family Name:*

Date:*

Address:*

Parent Cell Number*

Home Telephone:*

Email:*

Fax

Insurance Company Name:*

Policy No.:*

Please email admissions@ftiyeshiva.org a copy of the student's health insurance card (both sides of card please).

Student #1

Student Name:*

Date of Birth:*

Allergy to drugs/food:

Medical problems, past or current:

Names of current medications:

Student #2

Student Name:

Date of Birth:

Allergy to drugs/food:

Medical problems, past or current:

Names of current medications:

Student #3

Student Name:

Allergy to drugs/food:

Medical problems, past or current:

Names of current medications:

Write "Not Applicable" for any information that does not apply to your family.

Mother’s Name:*

Best E-mail (most frequently checked):

Cell Phone:*

Business Phone

Father’s Name:*

Business Phone*

Cell Phone:*

Fax

Student Physician’s Name(s):*

Telephone:*

Relative, (not parent), friend, and/or neighbor who may be contacted if parent cannot be reached:

Alternate Contact #1 Name:*

Relationship:*

Home Phone:*

Cell Phone:*

Alternate Contact #2 Name:

Relationship:

Home Phone:

Cell Phone:

ROUTINE CARE - I hereby give permission to Foxman Torah Institute aka Delaware Valley Torah Institute to administer first-aid care in emergency situations and to give my child(ren) Tylenol (acetaminophen), Ibuprofen, over-the-counter allergy medicine, and/or any other common household remedies when necessary.

I (parent or guardian), the undersigned, do hereby authorize FOXMAN TORAH INSTITUTE aka Delaware Valley Torah Institute as our general agent to any emergency care deemed advisable and to be rendered through general or specific supervision of any licensed physician or surgeon. It is understood that this authorization is given in advance of any specific need for treatment and is given to provide the authority to the aforesaid agent to give specific consent to any and all emergency treatment or hospital care which the physician in the exercise of his best judgment may deem advisable.

Name of Parent/Gaurdian who filled out this form:*

Emergency Information Form

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