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Health Certification Form for Students & Teachers

Please note that, for students, this form is to be filled in by the student's parent or guardian.

I would like the above named person to enter the Scarsdale Synagogue Temples Tremont and Emanu-El (“Scarsdale Synagogue”) building.  I understand that, in light of the COVID-19 pandemic, Scarsdale Synagogue will not allow any employee, congregant, student or visitor, including the above named person, to enter the building if such employee, congregant, student or visitor answers “YES” to any of the following statements.  I also recognize that any employee, congregant, student or visitor, including the above named person, will be denied entry if the Scarsdale Synagogue staff or its clergy reasonably believe that the above named person is experiencing symptoms of COVID-19. 

I hereby certify for the above named person (if I am a parent/guardian answering for a student) or for myself (if I am a teacher) that I am accurately answering all of the following statements:

If the answer to any one of the above questions is yes, the student OR teacher is not permitted to attend religious school on that day without express permission from Rabbi Gold. If you have concerns or questions please contact Rabbi Gold.

I have been advised and I understand that Scarsdale Synagogue cannot guarantee a completely COVID-19 free environment and that, if I consider the above named person to be high-risk for COVID-19, he/she should not enter the Scarsdale Synagogue building.  By signing below, I acknowledge and agree that, to the maximum extent permitted by law, Scarsdale Synagogue shall have no liability if the above named person is exposed to or contracts COVID-19 as a result of his/her presence in the Scarsdale Synagogue building.

Thu, May 26 2022 25 Iyar 5782