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Staff Emergency Form

Emergency Form - Each Staff Member must complete!
Staff Member's Full Name*

First Name Last Name
Staff Member's E-mail*
Mother's Info
Mother's name*

First Name Last Name
Mother's E-mail*
Mother's Home Phone Number
Mother's Cell Phone Number*
Mother's Work Phone Number
Father's Info
Father's Name*

First Name Last Name
Father's E-mail*
Father's Home Phone Number
Father's Cell Phone Number*
Father's Work Phone Number
Two Emergency Contracts
Emergency Contact 1 (local, not parent)
Emergency Contact 1*

First Name Last Name
Emergency Contact 1 Home #*
Emergency Contact 1 Cell #*

Emergency Contact 1 Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Emergency Contact 2 (local, not parent)
Emergency Contact 2*

First Name Last Name
Emergency Contact 2 Home #*
Emergency Contact 2 Cell #*

Emergency Contact 2 Address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Physician Information
Physician's name*

First Name Last Name
Physician's phone*

Physician's address*

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Preferred Hospital*
Dentist's name*

First Name Last Name
Dentist's phone*

Dentist's address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

In case of emergency and I cannot be reached, I give permission for Camp Gan Israel to call the contact people listed above.*

YES!
Signature*
Date*
Should be Empty:

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