Medical Forms:

Medical Information:

Student's Name: Grade (entering):

Up to date with vaccinations? YesNo

Please note that there are specific vaccination requirements for children entering Kindergarten and Sixth Grade.

Has there been any changes in your medical history in the last year?

Please mail a copy of immunizations and a copy of your child's most recent physical exam record to:

ATT: Administrator at Cheder Menachem , 1001 Finnegans Lane, North Brunswick NJ 08902
or email them to
[email protected]

You can find links to print out Dental Health Forms, Physical Health Forms and the Over the Counter Treatment Release Form on the School Forms Page.

Name of PCP: Phone:

Medical Policy Name & #:

Is there any special medical information that we should be aware of?

Any Allergies?


Emergency Contact Information:

Person to be contacted in case of an emergency when parents cannot be reached:

Name: Number:

Relationship to child:

Name: Number:

Relationship to child:



Nursing Services:

Existing legislation provides nursing services and funding for full time students in private schools. Included in these services, based on available state aid, is maintenance of student health records, audio and vision screenings, height and weight for all students, and scoliosis screenings for students in Grades 5 and above, as well as emergency nursing services related to illness or injury.

I give my permission for my child to receive nursing services.



Medical Release Form:

I hereby give consent to the administration of Cheder Menachem to take whatever medical measures they deem necessary, at my expense, for my child in the event of a medical emergency. I will assume full responsibility for all charges related to the above, and release the hospital, the school from any and all liability, claims and causes of actions arising in connection with the transportation and/or treatment of the student named below.

Signature: Date:



Trip Release Form:

I hereby permit my child to participate in all school activities and to join in school and class trips on and beyond school properties and use any transportation selected by Cheder Menachem.

Signature: Date: