Rehmah Academy

Location:
5100 N. Kevy Place,
Tucson, AZ 85704

Phone:
520-395 0730

"*" indicates required fields

Child's Information

MM slash DD slash YYYY
Child's Name*
Home Address*
Sex*

Parents' Details

Mother’s Full Name*
Home Address*
Father’s Full Name:*
Home Address*

Emergency Contacts

I authorize the following individuals to collect my child from the facility in case of emergency or if I cannot be contacted: (Pursuant to R9-5-304.B, at least TWO contact persons are required.
Emergency Contact 1 Name*
Emergency Contact 2 Name*
If Medical care is necessary, call Health Care Provider (A Health Care Provider is a physician, physician assistant or registered nurse practitioner.*
Name
Contact Telephone Number
 
In case of injury or sudden illness, I request that this individual be called first:*
The following individual(s) may NOT remove my child from the facility:
Custody papers have been provided and are on file at the facility.
(A licensee shall attach an enrolled child's written immunization record or exemption affidavit to the enrolled child's Emergency, Information and Immunization Record card.)

For information regarding current immunization requirements go to:

www.azdhs.gov/phs/immun/index.htm or contact the Arizona Immunization Program Office at (602)364-3630.

One of these items must accompany the EIIR card at all times:*
Max. file size: 50 MB.
Notification of immunizations needed sent to Parent(s) or Guardian(s):
mo/day/yr
mo/day/yr
mo/day/yr
Updated immunizations received and attached:
mo/day/yr
mo/day/yr
mo/day/yr

Medical Information

Is child allergic to food or other substances?*
Is child usually susceptible to infections and if so, what precautions need to be taken?*
Is child subject to convulsions and what should be our procedure if one occurs?*
Is there any physical condition that we should be aware of and what precautions should be taken (heart trouble, food problem, hearing impairment, hernia, etc.)?*
Father/Guardian Printed Name*
Signed Name*
MM slash DD slash YYYY
Mother/Guardian Printed Name*
Signed Name*
MM slash DD slash YYYY
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