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Yeshivas Kayitz

Ohr Temimim

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Ohr Temimim
Yeshivas Kayitz

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STUDENT'S INFORMATION

Student of

Mesivta of Thornhill

Other Mesivta

Student's Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your Phone

Emergency Contact

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

General Medical History

Is your child up-to-date with all immunizations?

Yes

No

Date of last Tetanus or DPT Vaccine:

MM slash DD slash YYYY

Does your child have any Food, Medication or Environmental Allergies?

Food

Medication

Environmental

None

Please list and explain any allergies:

Has your child had the Hepatitis B vaccine?

Yes

No

Medical Form

Chicken pox (Varicella)

Yes

No

Measles:

Yes

No

Significant medical history (surgery, injuries, serious illness):

List any medical problems (asthma, seizures, headaches):

Are any medications required?

Yes

No

List any medications taken regularly

In an emergency, does your child require additional assistance to evacuate?

Yes

No

Please describe:

In the event that your child care program must be evacuated, are there medications or supplies that must be taken with this child:

Yes

No

Medical Insurance Details

Name of Insurance Company:*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Policy Number*

Physical Examination

Height:

Weight:

Parent's Info

Parent's Email*

Parent's Phone Number*

What shiur are you in?

Father's first name

Father's last name

Father's phone number

Father's email

Mother's first name

Mother's last name

Mother's phone number

Mother's email

Do you have any health or medical concerns we should be aware of?

Price if paying by Credit Card $2150 USD

Price if paying by Check $2100 USD

Pay By

Check

Credit Card

paying by Check

Price:

paying by Credit Card

Price:

Total

Credit Card*

MasterCard

Visa

Supported Credit Cards: MasterCard, Visa

Card Number

Expiration Date Month Year

Security Code Cardholder Name

Billing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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Ohr TemimimYeshivas Kayitz

STUDENT'S INFORMATION

General Medical History

Medical Form

Medical Insurance Details

Physical Examination

Parent's Info

Ohr Temimim
Yeshivas Kayitz