This emergency form is for:*Camp Gan IzzySolon Chabad Hebrew SchoolSolon Chabad After CareChild #1Child's Name*First NameLast NameDate of Birth*1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberMonth12345678910111213141516171819202122232425262728293031Day2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920YearDoes 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 NameBirth Date*1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - DecemberMonth12345678910111213141516171819202122232425262728293031Day2019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920YearDoes 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 Only:I give permission for the Solon Chabad staff to apply sunscreen on my child/ren.*YesNoI give permission for my child/ren to take the deep water test (5 ft.).YesNoIf yes, please write the child's nameI give permission for Camp Gan Izzy staff to sign a trip waiver for my child/ren in the event that a trip has to be changed last minute, such as a rain cancellation.*YesNoSubmitShould be Empty: This page uses TLS encryption to keep your data secure.
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