TSNS Child Information Form - Form

Email for confirmation

Please use the (+) button to view and complete each section. To add another section for a second child, click the (+) button again.

Child Information

Child First Name

Child Middle Name

Child Last Name

Child Date of Birth

Date of Admission

Age At Admission

Child's Home Address

Child's Home Phone

Primary Language Spoken

Identifying Marks

Eye Color

Hair Color

Skin Color

Sex

Height

Weight

Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Relationship to Child

Home Address

Reachable Phone Number

Business Name

Occupation

Business Phone Number

Hours at Work

Child Health Information

Please use these fields to specify information about all of your children. Please indicate which child you are referring to when applicable.

Physician Name

Physician Address

Physician Phone Number

Allergies/Special Diets

Chronic Health Conditions? Please email individual health plans to lbanerji@templeshalom.org.

Any custody agreements, court orders, and restraining orders pertaining to the child? If yes, please also email to lbanerji@templeshalom.org

Special limitations or concerns?

Small Group and Large Group Transportation Plan and Authorization

My child(ren) will arrive at TSNS via:

My child(ren) will depart TSNS via:

E-Signature

Date

First Aid and Emergency Medical Consent

I authorize staff in the childcare program who are trained in First Aid/CPR to give my child First Aid/CPR when appropriate.

I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize the program to transport my child to the nearest medical care facility and to secure necessary treatment for my child.

Emergency Contacts (In order to be contacted)

Name

Address

Relationship to Child

Home Phone

Cell Phone

I give permission for my child to be released to this person.

Name

Address

Relationship to Child

Home Phone

Cell Phone

I give permission for my child to be released to this person.

Name

Address

Relationship to Child

Home Phone

Cell Phone

I give permission for my child to be released to this person.

Health Insurance Provider

Policy Number

Parent/Guardian Signature

Developmental History and Background Information

Teeth Brushing Authorization

The Department of Early Education and Care of the Commonwealth of Massachusetts has legislated that all children who eat a meal or spend more than four hours at school be offered the choice of brushing their teeth while at school.

Parents may determine whether or not they want their child to participate. If yes, all children must bring in a labeled toothbrush and toothpaste in their lunchbox daily.

Yes, I want my child's teeth brushed at school.

No, I do not want my child's teeth brushed at school.

Photo/Video Consent

Yes, Temple Shalom has my permission to use any recording, or other depiction of (whether by sound, video, photography or other means) or testimonials by (written or verbal) my child/ren or any family member for the purpose of promoting Temple Shalom and its programs. It is our policy to never post full names of children.

No, Temple Shalom does not have my permission to use any recording, or other depiction of (whether by sound, video, photography or other means) or testimonials by (written or verbal) my child/ren or any family member for the purpose of promoting Temple Shalom and its programs. It is our policy to never post full names of children.

Electronic Signature

By typing my name below, I hereby constitute that this is my electronic signature for legal purposes.