Hebrew School Universal Permission Form 2020-2021

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Family Name

I give permission for child/ren (Name/s)

I give permission for child/ren (Name/s) to participate fully in all activities of the Marsha Dane Stern Hebrew School for the 2020-2021 academic year. I understand that field trips will be adequately supervised, and transportation will be arranged either by parent carpools, school buses, or walking, and that I will be informed beforehand of all such trips.

I give permission for photos of my child/ren taken while participating in CSAIR events to be used for
promotional purposes including but not limited to the CSAIR website and CSAIR Marsha Dane Stern Hebrew School Facebook page.

I hereby empower the members of the Hebrew School staff, appointed by the principal of the Marsha Dane Stern Hebrew School, to act for me in case of an emergency. This power shall include the authority to bring my child to a hospital or other emergency medical provider when said staff person believes that emergency medical care may be indicated for my child.

Family Health Information

How many parents/guardians does the child have?

Parent 1 Full Name:

Parent 1 Home #:

Parent 1 Work #:

Parent 1 Cell #:

Parent 2 Full Name:

Parent 2 Home #:

Parent 2 Work #:

Parent 2 Cell #:

Parent 3 Full Name:

Parent 3 Phone #:

Parent 3 Work #:

Parent 3 Cell #:

Parent 4 Full Name:

Parent 4 Home #:

Parent 4 Work #:

Parent 4 Cell #:

In case of emergency contact the following # person/s:

Choose number of emergency contacts you wish to leave.

Emergency Contact 1 Name:

Emergency Contact 1 Phone #:

Emergency Contact 2 Name:

Emergency Contact 2 Phone #:

Emergency Contact 3 Name:

Emergency Contact 3 Phone #:

Emergency Contact 4 Name:

Emergency Contact 4 Phone #:

Doctor's Name:

Doctor's Phone #:

Insurance Company:

Insurance Policy #:

Are there any medical or dietary concerns or limitations to your child/ren full participation in any school program?

Parent Signature:

Date:

Mon, January 18 2021 5 Shevat 5781

Hebrew School Universal Permission Form 2020-2021

CSAIR :: 475 West 250th Street :: Bronx, NY 10471 :: 718-543-8400 :: info@csair.org