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Emek Nursery Camp Application

Emek Nursery Camp Application

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Published by Daniel Aharonoff

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Published by: Daniel Aharonoff on Dec 22, 2010
Copyright:Attribution Non-commercial

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04/06/2011

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EMERGENCY INFORMATION
:DOCTOR LAST NAME: DOCTOR FIRST NAME: DOCTOR PHONENUMBER:RELATIVE NAME: RELATIONSHIP: RELATIVE PHONENUMBER:OTHER EMERGENCYCONTACT:RELATIONSHIP: PHONE NUMBER:INSURANCE COMPANY: POLICY OR GROUPNUMBER:LIST ANYRESTRICTIONS:ALLERGIES TO DRUGSOR FOODS:IN THE EVENT THAT YOU ARE UNABLE TO REACH ME DURING ANY EMERGENCY,YOU ARE AUTHORIZED TO RELEASE MY CHILD TO ANY ONE OF THE ABOVEPEOPLE, OR TO TAKE MY CHILD TO A HOSPITAL EMERGENCY ROOM TO BETREATED.I HEREBY GIVE PERMISSION FOR MY CHILD TO PARTICIPATE IN ALL CAMP FIELDTRIPS AND ACTIVITIES.MOTHER’S SIGNATURE: _________________________________________FATHER’S SIGNATURE: _________________________________________

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