Medical Form

Medical Authorization Form

  • Please have your child's health insurance card handy (see end of form).

  • Contact Information

  • Date Format: MM slash DD slash YYYY




  • In case of Emergency

  • Please list two people to contact in case of emergency:
  • Medical Provider

  • Medical Information & History

  • Please describe any medical condition your son has and/or any medication he is taking
  • I hereby give permission for my son to receive any necessary medical treatment, including physician’s visits and treatments at local Medical Centers and hospitals. I also authorize the release of any medical information pertaining to my son to Mesivta Lubavitch of Monsey and its employees. I further certify that my son has medical insurance coverage valid in New York State.

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