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* 1 - January2 - February3 - March4 - April5 - May6 - June7 - July8 - August9 - September10 - October11 - November12 - December Month12345678910111213141516171819202122232425262728293031 Day20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Year Do you have any allergies?* YesNo If yes, please list Are there certain foods you avoid for any reason? Please detail. Staff members are required to wear the camp shirt every day. and we provide long-sleeved ones. Choose your size.* XSSMLXLXXL Parent Information 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 Emergency Contact Emergency Contact Person * First Name Last Name Phone Number* Area Code Phone Number In the event of an emergency, I give permission to Solon Chabad to transport my child to the nearest hospital and receive medical treatment.* Parent Signature Date of Signature Month Day Year at 123456789101112 Hour001020304050 MinutesAMPM Submit Should be Empty: This page uses TLS encryption to keep your data secure.
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