Emergency Consent and Contact Information

Family Name*

Number of children that will be attending the Hebrew Academy this year.*

Name of Student*

First Name Last Name

Name of Student (2)

First Name Last Name

Name of Student (3)

First Name Last Name

Name of Student (4)

First Name Last Name

Name of Student (5)

First Name Last Name

Name of Student (6)

First Name Last Name

Name of Student (7)

First Name Last Name

Name of Student (8)

First Name Last Name

EMERGENCY INFORMATION

I (we) the undersigned parent(s) or legal guardian(s) of the minor child(ren) listed above, do hereby authorize and consent for any x-ray examination, anesthetic, medical or surgical diagnosis rendered under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provision of the Medical Practice Act or a dentist licensed under the provisions of the Dental Practice Act and on the staff of any acute general hospital holding a current license to operate a hospital from the State o California Department of Public Health. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power to tender care which the aforementioned physician in the exercise of his best judgement may deem advisable. It is understood that efforts shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if he undersigned cannot be reached. This release only gives HEBREW ACADEMY and agents thereof, the right to consent to treatment of of minors. It does not release signee of liability from medical costs arising from said treatment. HEBREW ACADEMY does not assume responsibility of said cost and is not liable for any complications arising from said treatment.

Emergency Consent Signature - I give the Hebrew Academy permission to seek emergency medical treatment for my child/ren as outlined above.* By signing this agreement, I acknowledge that I have read, understand, and accept the terms of the Medical Agreement

First Name Last Name

Relationship to Child(ren)*

In situations where a parent cannot be reached:

Emergency Contact (1)*

First Name Last Name

Relationship to child(ren)*

Phone Number*

Area Code Phone Number

Emergency Contact (2)*

First Name Last Name

Relationship to child(ren)*

Phone Number*

Area Code Phone Number

The person(s) listed below are authorized to pick up my child(ren)
(other than parents)

Full Name

First Name Last Name

Relationship to child(ren)

Full Name

First Name Last Name

Relationship to child(ren)

Emergency Contact Information

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