Congregation Shaarey Israel Hebrew School

Emergency Contact Information- 2011-2012 (fill out one per child)

Please return this form to the synagogue office with your application

Student’s Name_______________________________Birth Date______________M/F___

Address____________________________City______________________Zip______________________

Home Phone______________________________Mother’s Cell#________________________________

Father’s Cell#_____________________________Primary Caretaker_______________Cell#___________

Emergency Contacts:

Contact #1

Name_______________________________________________Relationship to Student_____________

1^st Phone______________________________ ___Home ___Cell ___Work

2^nd Phone______________________________ ___Home ___Cell ___Work

3^rd Phone__________________________________ Home ___Cell ___Work

Contact #2

Name_______________________________________________ _Relationship to Student____________

1^st Phone______________________________ __ Home ___Cell ___Work

2^nd Phone______________________________      __ Home ___Cell ___Work

3^rd Phone______________________________ __Home ___Cell ___Work

Physician_______________________________________________________________________

Address_________________________________________________Phone _________________

Medical Insurance Co.____________________________________ Policy #________________________

Primary Insured Name______________________________________Birthdate_________________________

Special Concerns______________________________________________________________

In case of accident or serious illness, if the school is unable to reach a parent or emergency contact, I hereby authorize the school to call the physician indicated above and to follow his/her instructions. If the school is unable to reach this physician, Congregation Shaarey Israel has the authority to perform and seek emergency medical treatment.

Parent/Guardian Signature____________________________________________________Date_______