Temple Judea Authorization Request Form

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Please complete this form if you have children in Temple Judea's Religious School, Confirmation Academy, Teen Assistant Program or Youth Group.

Your name? *

Your child's name (or children's names)?
*

In the event of an emergency, we will make every effort to contact students' parents or guardians. In the event that we are unsuccessful, who else we could call? Please provide name, relationship, and all possible phone numbers.

Temple Judea and its representatives have my permission, in an emergency when my physician or I cannot be contacted, to administer care and treatment for my child (including, but not limited to, administering listed medications) for illness or injuries. The Temple Judea representative may hospitalize and/or secure medical treatment for my child in a medical emergency, if in his/her best judgment; further delay might jeopardize the welfare of my child. I agree to release and hold harmless Temple Judea and its representatives for administering or authorizing the administration of medical care to my child, providing they are following my written instructions on this Permission Form or are making a good faith attempt to provide for the welfare of my child in an emergency. I give permission to Temple Judea and its representatives to release pertinent medical information from my child's medical file in order to facilitate medical care.
*

Yes, Temple Judea may authorize emergency treatment in the event that I cannot be reached.

No, Temple Judea may NOT authorize emergency medical treatment in the event that I cannot be reached.

Temple Judea regularly use photographs, video images and quotations of students involved in school and synagogue activities in its publications, on its website or in other selected media for the purpose of promoting the school and its programs. Temple Judea will NOT publish your child’ name or other identifying information without your express permission.
*

I hereby give my permission for Temple Judea to share my child's image or words.

I do NOT give my permission for Temple Judea to share my child's image or words.

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