Grades 1-12 Health and Permission Form 2024-2025

Child/Family information

Child's name *

Which class will your child be enrolling in this school year? *

Emergency contacts

Emergency contact 1 name *

Emergency contact 1 phone number *

Relationship to child *

Parent

Neighbor

Friend

Family member (please indicate relationship) Family member (please indicate relationship)

Medical Information

Name of child's pediatrician: *

Phone number of Pediatric Office:

TN Immunization records: Mandatory for students enrolling in Pre-K 3, Kindergarten, 7th Grade and all new students.

Does your child have any allergies? *

Yes

No

If you answered "yes" to the above question, please list and explain your child's allergies and the methods to treat an allergic reaction:

Does your child have asthma? *

Yes

No

If you answered "yes" to the above question, please explain your child's method of treatment and plan for an asthmatic episode :

Has your child ever received any intervention services? (i.e. speech therapy, early intervention, occupational therapy, physical therapy, behavioral therapy, play therapy, or academic supports) *

Yes

No

If you answered "yes" to the above question, please list and explain your child's intervention services:

Parental Permission Release

I give my permission for MHA to contact my child's medical provider(s) in the event of an emergency: *

Yes

No

The faculty/ staff assigned responsibility for the care and education of my child has permission to access my child’s health records. *

Yes

No

I give permission for my child's photograph, digital or video recording, likeness, or artwork to be used in featured publications, web pages, or social media sites. Circulation of the materials could be worldwide and there will be no compensation to me or my child for the use. *

Yes

No

I hereby give permission for this student to participate in his/her class for school conducted field trips (you will be notified in advance by your child(ren)'s teacher of specific field trips - time and destination. *

Yes

No

I hereby give permission for this student to participate fully in gym class/school athletic teams. (Any restrictions must be accompanied by a doctor's note) *

Yes

No

I hereby give permission for this student to ride in school vehicles or personal automobiles driven by an adult staff member of the MHA/FYOS or any other adult designated by the school. *

Yes

No

I hereby give permission for this student to be tested and/or taught by the school's special education teacher for remediation and placement. *

Yes

No

I hereby give permission for this student to receive the manufacturer's recommended dosage of Ibuprofen or Acetaminophen when he/she comes to the office with a minor ailment and requests medication. I am aware that I will be called prior to the administration of this medication to avoid overmedication. *

Yes

No

For Dorm and Out of Town Parents Only - I (we), the undersigned parent(s) or legal guardian(s) of the minor student(s) listed on this form do hereby authorize and consent for any x-ray examination, anesthetic, medical or surgical diagnosis rendered under the general of special supervision of any member of the medical staff and emergency room staff licensed under the provisions of the Medical Practice Act or a dentists licensed under the provisions of the Dental Practice Act and on the staff of any acute general hospital holding a current license to operate a hospital from the State of Tennessee Department of Public Health. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required but is given to provide authority and power to tender care which the aforementioned physician in the exercise of his/her best judgment may deem advisable. It is understood that efforts shall be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached. This authorization is given pursuant to the provision of the Civil Code of the State of Tennessee. The signing of this release gives Margolin Hebrew Academy/Feinstone Yeshiva of the South and agents thereof, the right to consent for treatment of minors. It does not release signee of liability from medical cost arising from said treatment. Margolin Hebrew Academy/Feinstone Yeshiva of the South does not assume liability of said cost and is not liable for any complications arising from said treatment. This consent shall remain effective for the student's period of enrollment.

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Health Insurance Card for Out of Town Students - Students from outside Memphis must have a current health insurance card in their possession and must upload a copy of their card here.

Please provide any additional information you think we should know about your child: