Staff Emergency Form

This emergency form is for:*

Camp Gan IzzySolon Chabad Hebrew SchoolSolon Chabad After CarePreschool summer camp helpers
Name*
First Name Last Name
Date of Birth*

Month Day Year
Do you have any allergies?*

YesNo
If yes, please list
Emergency Contact
Emergency Contact Person *
First Name Last Name
Phone Number*

Area Code Phone Number
If under 18, please complete the following:
Mother's Name
First Name Last Name
Mother's Cell Phone Number

Area Code Phone Number
Mother's Email
Father's Name
First Name Last Name
Father's Cell Phone Number

Area Code Phone Number
Father's Email
In the event of an emergency, I give permission to Solon Chabad to transport my child/r to the nearest hospital and receive medical treatment.*
Parent Signature
Date of Signature

Month Day Year
at Hour Minutes
Should be Empty:

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Emergency Contact