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Jewish Community Day School of Rhode Island
85 Taft Avenue
Providence, RI 02906
(401)751-2470
FAX: (401)351-7674
Email: info@jcdsri.org

Student Emergency Form

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In case of illness or emergency, the parent(s) will always be contacted first. If the School Office personnel are not able to contact the parent(s), please indicate who should be called. It is understood that the student has permission to be released to the persons designated below.

You may use the online form below or download the Student Emergency form as a Word Document or PDF Document.

Student Info

Last Name

First Name

Date of Birth

Parent/Guardian 1

Name

Home Address

Phone

Cell Phone

Business

Business Address

Business Phone

Parent/Guardian 2

Name

Home Address

Phone

Cell Phone

Business

Business Address

Business Phone

Friend or Relative 1

Name

Address

Phone

Cell Phone

Friend or Relative 2

Name

Address

Phone

Cell Phone

Doctor

Name

Address

Phone

MEDICAL AUTHORIZATION

I authorize the Jewish Community Day School of Rhode Island to arrange for medical care for my child, , should an emergency arise at school or on a field trip. It is also understood that a conscientious effort will be made by the school to contact me or any of the emergency numbers I have provided for them before any medical action is taken. I understand that in the final disposition of an emergency case, the judgment of the school authorities will prevail. Any time the provided information must be changed, I will notify the school office.

The school has my permission to take my child to Hospital in the event of an emergency. My Health Insurance is with (provider):
and my Health Insurance Policy Number is

Parent(s) Signature g Date

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