EMERGENCY
CONTACT INFORMATION
(To be completed by a parent or guardian)
Name
of TJCC Participant: _____________________________________________________________
Date
of Birth: __________________
Grade: _______________________
Sex: _________________
Home
Address: ______________________________________________________________________
Home
Phone: __________________________ E-mail
address: ________________________________
Names
of Parents or Guardian(s):
________________________________________________________
Work
Phone(s): 1) _________________________________
2) ______________________________
Cell
Phone/Beeper: 1) _____________________________
2) _________________________________
In
the event of an emergency and I cannot be contacted, please call:
Name:
____________________________________________________________________________
Relation:
___________________ Phone: (h) _____________________ (w)
_______________________
Doctor’s
Name: ________________________________
Phone: ______________________________
Insurance
Company: _________________________________________________________________
Policy
Number: _____________________________________________________________________
List
any allergy or medical conditions of which we should be aware, and any
medication taken:
___________________________________________________________________________________
___________________________________________________________________________________
List
any dietary restrictions: (vegetarian, lactose intolerant, kosher,
diabetic, etc.)
___________________________________________________________________________________
___________________________________________________________________________________
I give
permission for my son/daughter _________________________ to attend the
event/s she/he has registered for, and certify that my child is capable of
participating in these activities. I
understand that for some of these trips (as indicated in program
descriptions) I am giving the JCC permission to take my child on a bus or
JCC van to various locations. The
JCC cannot assume responsibility or liability for accidents or loss
occurring on these trips. In
the event of an emergency where I (or my emergency contact) cannot be
reached, I authorize the JCC to secure medical treatment for my child.
I give permission to use any and all written comments, pictures, video and/or movies in which my child may appear for publicity, promotion, and advertising on behalf of Jewish Community Centers of Greater Boston.
Parent
or Guardians’ Signature: ______________________________________
Date: ______________
This
form will be kept on file at the Jewish Community Centers of Greater
Boston.
If any of the information changes, please contact the TJCC office at (617) 558-6512.