Medical and Allergy Form
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Student's Full Name *
Parent’s Name *
Parent's E-mail *
Parent's phone number *
My son is bringing prescription medication to Yeshiva *
If yes, please list names and dosages of medications:
If yes, how frequently does he take the medication?
My son has serious allergies to food or medication *
If yes, please specify allergy and degree of severity
My son has a medical condition that might interfere with his participation in Ashreinu programming *
If yes, please specify the condition
My son has a learning disability or ADD or ADHD *
If yes, Please specify all relevant details
My son has recently seen a therapist or psychiatrist *
If yes, Please describe the reason for consulting with a therapist
My son has emotional or social sensitivities that the Yeshiva should know about *
If yes, please specify
My son has sleep issues (i.e. sleep apnea, insomnia, etc.) *
If yes, please specify
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