If parent(s)/guardian(s) are not available in an emergency, please contact:

Emergency Contact #1

Emergency Contact #2

This health history is correct and complete to my knowledge. The person herein described has permission to engage in all program activities except as noted. I hereby give permission to Congregation Bet Ha'am Religious School to provide routine health care, administer medications and seek emergency medical treatment including ordering x-rays or routine tests. I agree to the release of any records necessary for insurance purposes. I give permission to Congregation Bet Ha'am Religious School to arrange necessary related transportation for my child. In the event that I cannot be reached in an emergency, I hereby give permission to the physician/health care provider selected by Congregation Bet Ha'am to secure and administer treatment, including hospitalization, for the person named above. This completed form may be photocopied, if needed, for trips off event premises

I understand that Congregation Bet Ha'am Religious School is not defined as an entity subject to HIPAA and therefore is not covered by HIPAA regulations concerning patient medical records. I also understand and agree that situations may necessitate that my child’s medical information be shared with the event staff and/or event medical staff. I give permission to any Health Care Provider, such as a hospital or physician to share my child’s medical information with the event medical staff, for treatment purposes.

I give my permission to Congregation Bet Ha'am Religious School to use any video of photograph, either online or in print, or any video taken at the event my child is attending for the putpose of markeing or promoting the congregation and its programs.