This emergency form is for:* Camp Gan IzzyHebrew SchoolAfter CarePreschool Summer Camp Helpers Child #1 Child's Name* First Name Last Name Date of Birth* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Does your child have any allergies?* YesNo If yes, please list If yes, please submit a Care Plan here. Does your child take medication on a daily basis?* YesNo Will your child need to take medication while at our program? YesNo If your child will need to take medication while at 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? Please explain Child #2 Child's Name* First Name Last Name Date of Birth* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Does your child have any allergies?* YesNo If yes, please list If yes, please submit a Care Plan here. Does your child take medication on a daily basis?* YesNo Will your child need to take medication while at our program? YesNo If your child will need to take medication while at 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? Please explain Child #3 Child's Name* First Name Last Name Birth Date* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Does your child have any allergies?* YesNo If yes, please list If yes, please submit a Care Plan here. Does your child take medication on a daily basis?* YesNo Will your child need to take medication while at our program? YesNo If your child will need to take medication while at 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? Please explain Emergency Contact Mother's Name* First Name Last Name Mother's Cell Number* Area Code Phone Number Mother's Email Father's Name First Name Last Name Father's Cell Number* Area Code Phone Number Father's Email Emergency Contact Person * First Name Last Name Relationship to child/ren* Phone Number* Area Code Phone Number In the event of an emergency, I give permission to Solon Chabad to transport my child/ren listed above to the nearest hospital and receive medical treatment.* Signature Date of Signature Month Day Year at 123456789101112 Hour001020304050 MinutesAMPM Camp Families Only I give permission to the Solon Chabad staff to apply lotion/sunscreen to my child/ren.I give permission for Camp Gan Izzy staff to sign a trip waiver for my child/ren. Please write the name of each child that may take the deepwater test. Submit Should 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.