Info and Authorization Form

This form is for students enrolled in Torah Tots.

Every Torah Tots must have emergency information on file with the school before the first day of classes.

One student per form.

You must complete all required fields in order to successfully submit the form.

STUDENT INFORMATION

Student's Name*

First Name Last Name

Student's Hebrew Name

Gender*

FemaleMale

Birth Date*

Month Day Year

Class:*

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PARENT INFORMATION

Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone

Area Code Phone Number

Mother's Name*

First Name Last Name

Mother's Cell #*

Area Code Phone Number

Mother's Work #

Area Code Phone Number

Mother's Email*

Father's Name*

First Name Last Name

Father's Work #

Area Code Phone Number

Father's Cell #*

Area Code Phone Number

Father's Email*

EMERGENCY CONTACT(S)

Please provide contact information for at least one individual outside of parents.

Emergency Contact #1 Name*

Emergency Contact #1 Cell #*

Area Code Phone Number

Emergency Contact #2 Name

Emergency Contact #2 Cell #

Area Code Phone Number

ALLERGIES, MEDICAL ISSUES, RESTRICTIONS

Please list your child's restrictions, chronic medical issues or allergies. Examples include food allergies, bee sting reactions, asthma, cardiac problems and any other medical conditions that are important for the school to know.

Please indicate:*

No Known AllergiesAllergy information below

Allergic to:

Possible symptoms if exposed to what child is allergic to:

Specific steps to take if my child has an allergic reaction:

Medical Condition or concerns

Medications being taken

Previous fracture or joint issues

MEDICAL EMERGENCY TREATMENT CONSENT

This grants permission to release information concerning treatment of my child to the representative from Torah Tots Academy accompanying him/her.

If, in the opinion of the properly licensed and practicing physician, my child needs medical or surgical services that require my authorization or consent before being supplied, I hereby authorize, appoint, and empower Torah Tots Academy to act as my agent to furnish on my behalf such oral or written authorization as which might arise from the giving by it of such authorization; it being my desire that my child be furnished with medical or surgical services as soon as reasonably possible after the need arises.

ARTICLE XIII, B, 1, PBC Rules requires the parents complete an AUTHORIZATION FOR EMERGENCY MEDICAL CARE in the event of serious illness or accident and if the parents cannot be reached. I authorize the child care center to obtain emergency medical care for my child.*

YesNo

Physician Name and Phone*

Dentist Name and Phone*

Student's Insurance Company*

Student's Policy/Group Number*

My child can be photographed and/or videotaped for the purpose of advertising, website and/or social media content, in-school purposes, and other marketing purposes.*

YesNo

I give permission for my name, phone number, and email to be included in the class list that will be distributed.*

YesNo

I give permission to Torah Tots to supply and apply, when appropriate, sunscreen product SPF-15 or higher when my child is outside during the school year.*

YesNo

I give permission to Torah Tots to take my child into the Chabad of Boca Raton building during the school day.*

YesNo

I allow my child to participate in food related activities such as baking and special occasions such as holiday or birthday parties wherein food is concerned, subject to conditions noted below:*

YesNo

Allergy or dietary restrictions* Indicate NONE if there are no restrictions

Parents and Torah Tots are working cooperatively to ensure that children are provided nutritious snacks and meals. I agree to provide a nutritious lunch and a mid-afternoon snack for my child.*

YesNo

Click here to read the Child Care Facility Brochure

Click here to read the Influenza Virus Brochure

Click here to read the Child Discipline Form

Click here to read the Distracted Adult Brochure

Click here to read the Torah Tots Parent Handbook

ARTICLE XV, B, 7, a, PBC Rules require that parents must receive a copy of the Child Care Facility Brochure, KNOW YOUR CHILD'S DAY CARE CENTER. I have received a copy of the Child Care Facility Brochure, KNOW YOUR CHILD'S DAY CARE CENTER. I understand and agree to the above statement.*

YesNo

I have read the Influenza Virus Brochure*

YesNo

ARTICLE IV, C, 5, PBC Rules requires that parents be notified in writing of the disciplinary practices used by the child care facility. I have received in writing the disciplinary practices used by this child care facility. I understand and agree to the above statement.*

YesNo

I have read the Distracted Adult Brochure*

YesNo

I have read the Torah Tots or Tamim Handbook* (whichever is applicable to the child on this form)

YesNo

Please list below family/friends that are authorized to pick up your child without prior notification.

Those authorized to pick up my child List all names in box provided.

We would like to notify grandparents when we are having special events.

Maternal Grandparents:

Maternal Grandparents address:

Maternal Grandparents email:

Paternal Grandparents:

Paternal Grandparents address:

Paternal Grandparents email:

I have provided information, consent, authorization and agreement where indicated, and the information I provided is accurate.

Type your first and last name, to be used as your electronic signature*

First Name Last Name

Please send a confirmation email to this address:*

EMERGENCY FORM

AUTHORIZATIONS

ACKNOWLEDGEMENTS

CARPOOL INFORMATION

GRANDPARENT INFORMATION

PARENT ELECTRONIC SIGNATURE