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Medical and Allergy Form
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* Indicates required question
Student's Full Name
*
Your answer
Parent’s Name
*
Your answer
Parent's E-mail
*
Your answer
Parent's phone number
*
Your answer
My son is bringing prescription medication to Yeshiva
*
Yes
No
If yes, please list names and dosages of medications:
Your answer
If yes, how frequently does he take the medication?
Your answer
My son has serious allergies to food or medication
*
Yes
No
If yes, please specify allergy and degree of severity
Your answer
My son has a medical condition that might interfere with his participation in Ashreinu programming
*
Yes
No
If yes, please specify the condition
Your answer
My son has a learning disability or ADD or ADHD
*
Yes
No
If yes, Please specify all relevant details
Your answer
My son has recently seen a therapist or psychiatrist
*
Yes
No
If yes, Please describe the reason for consulting with a therapist
Your answer
My son has emotional or social sensitivities that the Yeshiva should know about
*
Yes
No
If yes, please specify
Your answer
My son has sleep issues (i.e. sleep apnea, insomnia, etc.)
*
Yes
No
If yes, please specify
Your answer
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