Teen Center Emergency Form
Sinai Teen Center Emergency Form
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Email *
Teen Name (First and Last) *
Teen Grade for the 2019-2020 School Year *
Teen Gender *
Teen's School for the 2019-2020 School Year *
Teen's Primary Address *
Parent/Guardian 1 Name *
Parent / Guardian 1 E-Mail *
Parent/Guardian 1 Home Phone *
Parent Guardian 1 Work Phone *
Parent/Guardian 1 Cell Phone *
Parent / Guardian 1 Address *
Parent / Guardian 2 Name *
Parent / Guardian 2 E-Mail *
Parent / Guardian 2 Home Phone *
Parent / Guardian 2 Work Phone *
Parent / Guardian 2 Cell Phone *
Parent / Guardian 2 Address *
Primary Emergency Contact for Teen *
Relationship to Teen *
Cell Phone *
Home Phone *
Secondary Emergency Contact for Teen *
Relationship to Teen *
Home Phone *
Cell Phone *
Parent / Guardian Signature (Please Print Name) *
Date *
MM
/
DD
/
YYYY
We have read the Sinai Temple Teen Center Policies and agree to their terms *
Required
Date of last Tetanus Booster (Td/Dtap) *
MM
/
DD
/
YYYY
Date of last Meningococcal Vaccine *
MM
/
DD
/
YYYY
Date of last Chicken Pox Vaccine (Varicella) or date of disease history *
MM
/
DD
/
YYYY
Please list any medical issues or conditions we should be aware of.   *
Is your child currently taking any medication? *
Name of Medical/Health Insurance Provider *
Policy Number *
Group Number *
Physician Name *
Physician Phone Number *
I acknowledge and accept Sinai Teen Center's policy to use licensed drivers over the age of 18 at all times. Usually, this means that we've rented a bus, a limousine, and/or similar transportation company, or that our staff is driving. With full understanding of this policy and the risks involved, I give permission for my child to ride in a properly insured vehicle driven by a licensed driver over the age of 18. *
Required
 If there is a shortage of licensed drivers of the age of 18, I do or do not give my consent for my child to ride with a licensed driver under the age of 18. *
Parent Signature *
I understand that children under the age of 18 are not allowed to use ride-sharing services without a guardian over 18 years of age present, and therefore may not take Uber/Lyft to and from our programs. *
Parent Signature *
Any minor attending Teen Center events has been instructed by me and understands and agrees to comply with all rules, regulations, and Code of Conduct established by Sinai Temple Youth Department and the official instructions and directives of all authorized staff members, volunteers, agents, and employees (“personnel”) of Sinai Temple. *
Required
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