This emergency form is for:*Camp Gan IzzySolon Chabad Hebrew SchoolSolon Chabad After CarePreschool summer camp helpersChild #1Child's Name*First NameLast NameDate of Birth*1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberMonth12345678910111213141516171819202122232425262728293031Day2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920YearDoes your child have any allergies?*YesNoIf yes, please write what the allergies areIf the allergy pertains to our program, please submit a Care Plan here.List any serious illnesses or operations your child has had.Is your child on an IEP in school? ExplainChild #2Child's Name*First NameLast NameDate of Birth*1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberMonth12345678910111213141516171819202122232425262728293031Day2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920YearDoes your child have any allergies?*YesNoIf yes, please write what the allergies areIf the allergy pertains to our program, please submit a Care Plan here.List any serious illnesses or operations your child has had.Is your child on an IEP in school? ExplainChild #3Child's Name*First NameLast NameBirth Date*1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberMonth12345678910111213141516171819202122232425262728293031Day2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920YearDoes your child have any allergies?*YesNoIf yes, please write what the allergies areIf the allergy pertains to our program, please submit a Care Plan here.List any serious illnesses or operations your child has had.Is your child on an IEP in school? ExplainEmergency ContactMother's Name*First NameLast NameMother's Cell Number*Area CodePhone NumberMother's EmailFather's NameFirst NameLast NameFather's Cell NumberArea CodePhone NumberFather's EmailEmergency Contact Person (if parents cannot be reached)*First NameLast NameRelationship to child/ren*Phone Number*Area CodePhone NumberIn the event of an emergency, I give permission to Solon Chabad to transport my child/ren listed above to the nearest hospital. I give my consent for emergency medial treatment to be used if necessary.*SignatureDate of SignatureMonthDayYearat 123456789101112Hour001020304050MinutesAMPM Camp Families OnlyI give permission to the Solon Chabad staff to apply lotion and sunscreen to my child/ren as needed.I give permission for Camp Gan Izzy staff to sign a trip waiver for my child/ren.I give permission for my child/ren to take the deep water test (5 ft.).Please write the name of each of your children that may take deepwater test.SubmitShould be Empty: This page uses TLS encryption to keep your data secure.
This page uses TLS encryption to keep your data secure.
This page uses TLS encryption to keep your data secure.
This page uses TLS encryption to keep your data secure.