STUDENT MEDICAL INFORMATION FORM 2021-2022

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Please fill out a separate form for each child.

Child's Name *

Date of Birth *

YYYY

Grade *

This child is current with all required immunizations in accordance with the requirements of 28 PA Code Ch.23 (School Immunization) *

Yes

If no, please provide reason and a copy of your medical, religious/philosophical waiver or medical certificate.

Please describe any medical issues that will affect child's time in Torah Center. If none, please indicate. *

Please list any and all allergies. If none, please indicate. *

Has your child been prescribed epinephrine or an Epi-Pen?

If yes, please provide an Epi-Pen and an allergy action plan to the Education Office.

Yes

Clear selection

Please describe this child's learning interests and strengths. *

Does this child have an IEP or 504? *

Yes

If yes, would you be willing to share it with us?

Yes

Clear selection

Please describe any other special issues or needs.

Is it ok to share this information with your child's teachers?

Yes

Clear selection

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.

Yes

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 *

YYYY

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