Emergency Form

Taste of Camp Keshet Summer 2022

Camper Information

Child's first name:

Child's last name:

Gender:

MaleFemaleNon Binary

Child's date of birth:

Home phone number:

Home address:

In case of emergency, please contact:

Parent #1 - Full name:

Parent #1 - Address:

Parent #1 - Work Phone:

Parent #1 - Cell Phone:

Parent #1 - Email:

Parent #2 - Full name:

Parent #2 - Address:

Parent #2 - Work Phone:

Parent #2 - Cell Phone:

Other - Full name:

Other - Address:

Other - Work Phone:

Other - Cell Phone:

Pediatrician - Full name:

Pediatrician - Address:

Pediatrician - Phone:

The following people are authorized to pick up my child from camp. I understand that my child will not be released to anyone who does not appear on this list without written consent.

Adult #1 - Full name:

Adult #1 - Relationship to child:

Adult #1 - Cell phone:

Adult #2 - Full name:

Adult #2 - Relationship to child:

Adult #2 - Cell phone:

Adult #3 - Full name:

Adult #3 - Relationship to child:

Adult #3 - Cell phone:

Adult #4 - Full name:

Adult #4 - Relationship to child:

Adult #4 - Cell phone:

*This section must be completed.* You may indicate "none" if there are no known allergies.

Allergy information:

Agreement: I consent to the enrollment of my child at Camp Keshet and have been advised of the policies regarding fees and the services provided by this facility. I agree that in the case of accident or injury, emergency medical care may be given in the event that I or person named cannot be reached.

Parent initials

Contact Information