Permission to Release Form

In the event of an emergency, it is critical that you identify individuals who may pick up your child. Rest assured that if you are unable to contact these individuals or contact camp, your child will be cared for until you are able to do so.

Should you need someone to pick up your child, you must notify the office with all details. Your child will not be released to anyone without verbal or written permission. If the person you request is not on this list, we will not release your child. If you would like to add a name, you must send in a signed note indicating that you wish to add a name to your child’s list.

Please list below, all individuals who your children may be released to.
Child's Information:

Child 1:
Child's Name:*
Birth Date:*

Month Day Year
Age:*
Sex:*
Child 2:
2: Child's Name:
2. Birth Date:

Month Day Year
2. Age:
2. Sex:
Child 3:
3: Child's Name:
3. Birth Date:

Month Day Year
3. Age:
3. Sex:
The Following People May Pick Up my Child(ren) from Camp Gan Israel:
1. Full Name:

First Name Last Name
DL#:
Relation:

Address:

Address:

Address:

Address:

Address:

Address:

Phone Number:

Area Code Phone Number
Note: Any person unfamiliar to our staff will be required to show proof of identification. Under NO circumstances will the child be released to anyone other than those listed above without WRITTEN permission from the parent.

This form is legally binding, so by signing it, you agree that all of the information provided herein is correct.
Father/Guardian's Signature:*
Date:*

Month Day Year
Mother/Guardian's Signature:*
Date:*

Month Day Year
Should be Empty:

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Child's Information: