Emergency Procedure Form 2019-2020

Parents must notify the office if any vital information changes

Student Information

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Father's Information

Guardian's Information

Is the Father remarried? *
Please make sure to inform us as soon as a Baltimore address is available
If there is no home phone, please select this checkbox
Please select your default phone number:
 

Mother's Information

Guardian's Information

Is the Mother remarried? *
Please make sure to inform us as soon as a Baltimore address is available
If there is no home phone, please select this checkbox
Please select your default phone number:
 

Emergency Contact Information

List 3 people authorized to pick up your child in an emergency, or unusual circumstance, if you cannot be reached. Please notify the office if your child will be picked up by someone other than the parent in a non-emergency situation.

Emergency Contact Information *
 NameRelationshipPrimary Phone Number
Contact 1
Contact 2
Contact 3

HEALTH INFORMATION

In the event of an emergency, it is imperative that we have your child’s updated health information
Health Information *
 NamePhone NumberAddress
Pediatrician

EMERGENCY TREATMENT CONSENT

In the event of an emergency where the school is unable to reach me, I hereby give consent for the Talmudical Academy School Nurse, or other healthcare providers or designated school staff considered appropriate by the School Nurse, to carry out accepted procedures for my child, including the administration of first aid and/or CPR. I give consent for the School Nurse or designated healthcare providers/school staff to seek emergency treatment for my child, including transporting my child to the nearest hospital or other emergency care facility deemed appropriate and for the hospital or emergency care facility and its medical staff to provide my child with emergency medical treatment which a physician deems necessary (including anesthesia). I agree to accept financial responsibility for all medical expenses incurred. I give consent for any medical/psychiatric information to be released regarding my child's health situation to the School Nurse and/or other administrative authorities/healthcare providers, if necessary. I give consent for the emergency administration by a school representative of epinephrine with an autoinjector when anaphylaxis is indicated.

Parent Signature *
clear
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PHOTO & VIDEO CONSENT

I hereby grant Talmudical Academy permission to use printed or electronic photographs and video footage of my child taken during school-sponsored activities for publicity and/or educational purposes. This may include, but is not limited to, the TA website, newsletter and/or printed materials. I understand that if my child’s image is used, all efforts will be taken to safeguard his/her privacy.
Parent Signature *
clear
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GRANDPARENTS

Please do not contact Grandparents

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Please do not contact Grandparents

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Please do not contact Grandparents

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