STUDENT MEDICAL INFORMATION FORM 2022-2023
Please fill out a separate form for each child.
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Email *
Child's Name *
Date of Birth *
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Grade *
This child is current with all required immunizations in accordance with the requirements of 28 PA Code Ch.23 (School Immunization) *
If no, please provide reason and a copy of your medical waiver or medical certificate.
Please describe any medical issues that we need to be aware of. *
Please list any and all allergies.  If none, please indicate. *
Has your child been prescribed epinephrine or an Epi-Pen?
If yes, please provide a non-expured Epi-Pen and an allergy action plan to the Education Office prior to the start of the year.
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Please describe this child's learning interests and strengths. *
Does  this child have an IEP or 504? *
Please describe anything else you would like us to know!
Medical Release *
If I cannot be reached in the event of an emergency, I give permission to the physician selected by our Torah Center staff to hospitalize, secure proper treatment for, and order injection, anesthesia or surgery for my child.
Physician's Name and Phone Number *
IF YOU HAVE INDICATED THAT THIS CHILD HAS A SERIOUS MEDICAL CONDITION, PLEASE MAKE CERTAIN THAT EMERGENCY MEDICINE IS LEFT IN THE TORAH CENTER OFFICE WITH PRECISE INSTRUCTIONS SIGNED BY YOU.
Parent/Guardian Signature *
Date *
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