Solon Chabad Emergency Medical Form

 

REQUIRED FIELD:  Check off the program your child is attending. 

This
 emergency form is for  Camp Gan Izzy      After Care        Hebrew School


Children's Info
Child 1

Child's Name
Date of Birth
Does your child have any allergies?*
If the allergy pertains to our program, submit a Care Plan here. 
List any serious illnesses or operations your child has had.
Is your child on an IEP in school? Explain

Child 2

 
Child's Name
Date of Birth
Does your child have any allergies?*
If the allergy pertains to our program, submit a Care Plan here. 
List any serious illnesses or operations your child has had.
Is your child on an IEP in school? Explain

 

Child 3

Child's Name
Date of Birth
Does your child have any allergies?*
If the allergy pertains to our program, submit a Care Plan here. 
List any serious illnesses or operations your child has had.
Is your child on an IEP in school? Explain


Emergency Contact Info

Mother's Name
Mother's Cell Number*
Mother's Email
Father's Name
Father's Cell Number*
Father's Email
Emergency Contact Person* (if parents cannot be reached)
Relationship to child/ren*
Phone Number*

 

Camp families only:  
I give permission for the Solon Chabad staff to apply sunscreen on my child/ren.
 I give permission for my child/ren  to swim in the deep end of the pool (5 ft.).
 

In the event of an emergency, I give permission to Solon Chabad to transport my child/ren*
to the nearest hospital. I give my consent for emergency medial treatment to be used if necessary.

Signature* Date*