Svivot Medical Form - Bnei Akiva UK

Please fill in a separate form for each child attending Sviva

Child's Name*
First Last
Date of Birth*
DD slash MM slash YYYY
Sviva*
This is the location of your Bnei Akiva group e.g. Golders Green
Hidden
Shevet
Shevet (Year Group)*
Emergency Contact Name*
First Last
Emergency Contact Mobile Number*
Emergency Contact Home Telephone Number*
Email address*
Emergency Contact Address*
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Does your child suffer from any allergies that we should be aware of? e.g. Plasters, penicillin, food? Please give full details below. Withholding information may endanger the health or well-being of your child.*
Please give full details of any physical health conditions that may affect your child at sviva. e.g. Asthma, diabetes, epilepsy. Withholding information may endanger the health or well-being of your child.*
Please give full details of any mental health condition that may affect your child at sviva. e.g. ADHD, eating disorders, anxiety. Withholding information may endanger the health or well-being of your child.*
Approximate date of last Tetanus injection*
Do you feel that your child will need any extra support at sviva? If so, please contact Ruth Kramer on 02082091319 ext.7*
Terms and conditions (to be signed by parent/guardian if under 18)*
- I hereby declare that to the best of my knowledge, tthis medical form is accurate and complete in all its details. I understand that Bnei Akiva will not be responsible for any medical condition either physical or emotional, which may result from my failure to disclose relevant information. It is permissible for the designated First Aider to administer Savlon and plasterse, etc., for any minor ailments. I have read and agree to the above conditions.
I am happy to be added to any local Facebook or WhatsApp groups where information about my local Sviva will be shared by the Rosh and Madrichim.
- Yes
- No
I give permission for Bnei Akiva and Bachad to contact me and those listed in this form in regards to Bnei Akiva/Bachad events.
- Agree

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Bnei Akiva Svivot Medical Form

Please fill in a separate form for each child attending Sviva

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