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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, whether for Jewish Youth Choir, or for Religious/Hebrew School or Teen Programming. This form AND the 2019-2020 Religious and Hebrew School Registration Form available here, AND/OR the Teen Programming Registration Form available here, must all be received, as well as a 2019-2020 Bet Haverim Partnership Form (for Religious/Hebrew School registrations, available here), for your child(ren)’s/teens’ enrollment to be complete.

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

  • If applicable
  • If applicable
  • Please provide at least two names, with home and mobile phone numbers, as well as relationship to student, for each contact listed
  • 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.
  • 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.

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