2021-2022 Medical/Confidential Information - Form - Suburban Temple - Kol Ami

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2021-2022 Medical/Confidential Information

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LEARNER # 1

Learner # 1 First Name

Learner # 1 Last Name

Learner # 1 Food Allergies

Please list any food allergies

Learner # 1 Medicine Allergies

Please list any medicine allergies

Learner # 1 Doctor's Name

Doctor's Phone Number

COVID-19 Vaccination Status

YesNoThis learner has or has not received their full COVID-19 vaccination.

(For 12th grade or below) Knowing yourself/your child better than anyone, what should we know about you/your child to create the best learning environment? (If your child has an IEP or 504 Plan, please email it to Rabbi Shana).

Are there any family situations (e.g. divorce, illness) of which we should be made aware?

LEARNER # 2

Learner # 2 First Name

Learner # 2 Last Name

Learner # 2 Food Allergies

Please list any food allergies

Learner # 2 Medicine Allergies

Please list any medicine allergies

Learner # 2 Doctor's Name

Doctor's Phone Number

COVID-19 Vaccination Status

YesNoThis learner has or has not recevied their full COVID-19 vaccination.

(If 12th grade or below) Knowing yourself/your child better than anyone, what should we know about you/your child to create the best learning environment? (If your child has an IEP or 504 Plan, please email it to Rabbi Shana).

Are there any family situations (e.g. divorce, illness) of which we should be made aware?

LEARNER # 3

Learner # 3 First Name

Learner # 3 Last Name

Learner # 3 Food Allergies

Please list any food allergies

Learner # 3 Medicine Allergies

Please list any medicine allergies

Learner # 3 Doctor's Name

Doctor's Phone Number

COVID-19 VACCINATION STATUS

YesNoThis Learner has or has not received full COVID-19 vaccinations.

(For 12th grade or below) Knowing yourself/your child better than anyone, what should we know about you/your child to create the best learning environment? (If your child has an IEP or 504 Plan, please email it to Rabbi Shana).

Are there any family situations (e.g. divorce, illness) of which we should be made aware?

LEARNER # 4

Learner # 4 First Name

Learner # 4 Last Name

Learner # 4 Food Allergies

Please list any food allergies

Learner # 4 Medicine Allergies

Please list any medicine allergies

Learner # 4 Doctor's Name

Doctor's Phone Number

COVID-19 VACCINATION STATUS

YesNoThis Learner has or has not received full COVID-19 vaccinations.

(If 12th grade or below) Knowing yourself/your child better than anyone, what should we know about you/your child to create the best learning environment? (If your child has an IEP or 504 Plan, please email it to Rabbi Shana).

Are there any family situations (e.g. divorce, illness) of which we should be made aware?

LEARNER # 5

Learner # 5 First Name

Learner # 5 Last Name

Learner # 5 Food Allergies

Please list any food allergies

Learner # 5 Medicine Allergies

Please list any medicine allergies

Learner # 5 Doctor's Name

Doctor's Phone Number

COVID-19 VACCINATION STATUS

YesNoLearner has received full COVID-19 vaccinations.

(If 12th grade or below) Knowing yourself/your child better than anyone, what should we know about you/your child to create the best learning environment? (If your child has an IEP or 504 Plan, please email it to Rabbi Shana).

Are there any family situations (e.g. divorce, illness) of which we should be made aware?

Mon, May 23 2022
22 Iyar 5782

Mon, May 23 2022 22 Iyar 5782

SUBURBAN TEMPLE - KOL AMI

22401 CHAGRIN BOULEVARD
BEACHWOOD, OHIO 44122
(216) 991.0700

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