Child's Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Does your child take any medications on a regular basis? *

Yes

No

Does your child have any allergies towards food or medication? *

Yes

No

Does your child have need for an epi-pen? *

If yes, please provide a current epi-pen and written permission to administer to Battersea Hebrew Club at the beginning of the school year

Yes

No

I authorize the director or director's designee to seek appropriate medical care for my child, if necessary. *

Yes

Emrgancy Contact 1 *

First Name

Last Name

Phone *

Country

(###)

###

####

Emergency Contact 2 *

First Name

Last Name

Phone *

Country

(###)

###

####

In case of medical emergency requiring immediate emergency care, I authorize the emergency services to take my child to the nearest hospital if necessary. It is understood that I will hold BHC harmless for the nature and outcome of any emergency medical treatment. It is also understood that I leave the decision of what constitutes an emergency to the sole direction of the staff *

Yes

I hereby give permission for my child to participate in all school activities, join in class and school trips on and beyond school properties. *

Yes

I give permission for photos of my child taking part in Battersea Hebrew Club activities to be shared on social media and used in printed materials. *

Yes

No

Please enter your name as your signature *

First Name

Last Name

Today's date

MM

DD

YYYY