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Emergency Medical Information Form

Please complete one form for each child or teen you are enrolling. After submitting your first form, please refresh the page and fill out subsequent forms for additional children or teens.

Please note that this form alone does not suffice as enrollment for Religious/Hebrew School or Teen Programming. You must also complete the 2024-2025 Religious and Hebrew School Registration Form AND/OR Teen Programming Registration Form and be a Congregation Bet Haverim Partner in good standing in order for your child or teen’s enrollment to be complete. Click here to access the 2024-2025 Bet Haverim Partnership Form.

All information submitted on this form will be kept strictly confidential.

An asterisk following a heading indicates that this is required information.
Your Email address*
Student's Name
First Last
Student's Email address

If applicable
Student's 2024-2025 Religious School/Teen Programming grade*
Student's 2024-2025 Hebrew School level
If applicable
Parent 1 Name*
Parent 1 Mobile Phone*
Parent 1 Home Phone
Parent 2 Name
Parent 2 Mobile Phone
Parent 2 Home Phone
Additional emergency contacts if parents cannot be reached*
Please provide at least two names with home and mobile phone numbers, as well as relationship to student, for each contact listed
Name of student's Physician*
Physician's Phone number*
Name of student's health insurance carrier*
Health insurance policy number*
Consent to emergency treatment
I agree, and give permission for emergency care.
If the above physician is not available, Congregation Bet Haverim has my/our permission to take the student listed on this form to the nearest medical facility for emergency care.
Additional information about my child or teen
Please use this space to provide any information regarding your child or teen that may affect his/her participation in our program (e.g chronic or recurring illness, medications, food or medication allergies, ADD/ADHD, learning disability, etc.), or any other information that may be of value for your child's or teen's teacher(s) to be aware.
Signature of Parent or Guardian*
First Last
By typing my name above, I confirm the accuracy of all information provided above, as well as give my permission for CBH to seek any needed emergency medical treatment for my child or teen if I or one of the other emergency contacts cannot be reached in a timely manner.

Emergency Medical Information Form

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