Medical Information

Physician's Name

Telephone

Hospital Preference

Do you have medical insurance?

Yes No

Insurance Company

Policy Number

Please list any special medication conditions of which the school should be aware. (Include treatment for ADD, ADHD, or other.)

Emergency Contactrequired

Home Phonerequired

Cell/Work Phonerequired

Authorized Adults for Pick-uprequired

Waiver

In the event that my child needs medical attention, I authorize the school and give my consent to the school to provide such service and/or to transport my child to a hospital or treatment facility. I hereby certify that my child is in good health and may participate in all activities.

I give consent to provide medical attention I do NOT give consent to provide medical attention

I give permission to Portland Jewish Academy (PJA) to use images of my child in promotional materials related to PJA and PJA Summer Discovery. This includes, but is not limited to, PJA materials both printed and electronic, PJA Summer Discovery and Portland Jewish Academy Facebook pages, and third party materials as it relates to the promotion of PJA and PJA Summer Discovery. I understand that my child’s name will not be used in conjunction with their photo unless separate permission has been requested nor will my name as parent/guardian be tagged or identified by PJA in the materials.

I give permission to PJA to use images I do NOT give permission to PJA to use images

I give my permission for my child to ride in school-approved transportation to program activities. I agree to abide by school policies as set out on www.pjaproud.org

I give permission for transportation I do NOT give permission for transportation

By checking this box I give my signature of approval*

I approve everything in this application above.

Terms and Conditions

The personal information above is correct and complete as far as I know, and the person herein described has permission to engage in all PJA program activities except as noted. I hereby give permission to Portland Jewish Academy to provide routine health care, administer prescribed medications, and seek medical treatment. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. I give permission to PJA to arrange necessary related transportation for my child. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by PJA to secure and administer treatment, including hospitalization, for the student named above.

Use of any recreational facility and participation in any activity involves a risk of accidental injury despite all safety precautions. I/we have been informed of the activities to be conducted by the Portland Jewish Academy. I/we, as an individual or as a parent or guardian of the student named herein, assume all risks and hazards incidental to the activities, and release from responsibility and all liability, claims, costs, and damages including attorney fees and costs. I/we further agree to indemnify and hold harmless the Mittleman Jewish Community Center and Portland Jewish Academy, their officers, directors, independent contractors, volunteers, and all employees for any illness, injury or damage to me or my children, or my family members occurring during the use of any recreational facility or the participation in any activities conducted by the MJCC, MJCC Day Camp, or Portland Jewish Academy. Portland Jewish Academy reserves the right to cancel any activity based on insufficient enrollment. In the event that a program is canceled by PJA, all fees will be refunded within 30 days.

By checking the box below, I acknowledge that I have read, understand, and accept the above information as well as the additional policies outlined in the Terms and Conditions.

I agree to the Terms and Conditions