2023-24 Religious School Part Two - Medical and Emergency Info - Form

This form is required of all students.
Safety is our first priority.

Parent or Caregiver Information

First Name

Last Name

Preferred Pronouns

Cell Phone

Home Phone

Relationship to child or teen

Describe Relationship

Address

City

Zip

Does child or teen live with this adult full time?

Please describe living arrangement

First Name Adult 2

Last Name Adult 2

Preferred Pronouns

Cell Phone

Home Phone

Relationship to child or teen

Describe Relationship

Address

City

Zip

Does child or teen live with this adult full time?

Please describe living arrangement

List Child(ren) or Teen(s) Enrolling in Programs

Child First Name

Child Last Name

Child Birth Date

Important Emergency Information

Family Member Emergency Contact:

* Name

* Relationship

Please specify

This person is authorized to pick up or drop off my child

* Cell Phone

Other Phone

Notes

Non - Family Emergency Contact:

* Name

* Relationship

* Please specify

This person is authorized to pick up/drop off my child.

* Cell Phone

Other Phone

Notes

Medical Information

Name of Family Physician

* Physician Phone Number

* Name of Clinic / Practice

Clinic Address

Medical Insurance Provider

Policyholder Name

Policy / Group #s

* Please provide important information for all your child(ren) or teen/s about medical conditions and medications, including possible side effects we may see at school:

* Please list any allergies your child/ren or teen/s has, e.g. insects, food, drugs or anything else. If none, please write NONE.

Does your child/ren or teen/s have an IEP or learning needs? Please describe here.

Upload IEP form here (not required)

Release of Liability:

By checking yes, under the terms of this Agreement, the Releasor hereby releases, acquits and discharges any and all claims arising from or related to their entry and participation in the legal relationship resulting from the parent/guardian and child/ren with Congregation Nevei Kodesh - including, but not limited to, all obligations, pecuniary loss and intangible damages, the types of claims for personal injury, property damage or any other Claims arising from or related to the undersigned's entry into and participation in the activities.

The Releasor understands this release shall not constitute as an admission of guilt or any wrongful act with respect to Releasor, neither does this admit any liability which the Releasor may cleaim as of right against the Release.

Should a complaint be filed in any competent court by the Releasor in connection to this release, the Releasor voluntarily withdraws, revokes, desists, in pursuing the complaint against Release.

This Release inures the benefit of the heirs, successors, assigns, and representatives of parties. This Agreement and its validity, and any claim, controversy or dispute arising under or related to this Agreement shall be governed by and construed in accordance with the laws of the State of Colorado.

Both parties represent that they have read and fully understand the contents of this Agreement and they have freely and voluntarily subscribe to this Release Agreement.

Check here to agree to the terms in the Release of Liability Agreement Above

Date

Medical Release

By checking the box below I give my permission for my child/ren or teen/s to receive emergency medical transportation and treatment if it becomes necessary and neither the family nor other emergency contact can be reached.

Please Select OneYes!Not for us

Date:

Field Trip Release

By checking the box below I give my permission for my child/ren or teen/s to attend field trips during school hours with trained Nevei Kodesh staff. I understand that I will receive notice of fieldtrip travel prior to my child or teen attending.

Please Select OneYes!Not for us

Date:

Photo Release

By checking the box below I give my permission for my child/ren or teen/s to be included in photos and/or videos of classes and events, and for Nevei Kodesh to use those images in any print or online publicity such as, but not limited to, website, brochures, flyers, press releases, private Facebook page, etc. We will not list a child's first or last name in any of our promotional photos.

Please Select OneYes!Not for us

Date:

Yay - nearly there! Here is your last step to completing registration

When you click the button below to finalize your registration, you should receive an email confirmation of registration. If you do not, your form didn't go through, so please call our office, 303-443-4567.

SEE YOU SOON!