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Ohev Sholom - The National Synagogue

youth@ostns.org

1600 Jonquil Street NW, Washington, DC, 20012, US

202-882-7225

Household Information

Household Mailing Address

Additional Household Mailing Address

Parent/Guardian 1 Contact Information

Full Name

Parent/Guardian 2 Contact Information

Full Name

Emergency Release Information

Medical Insurance Information

Emergency Contact Information

Should my child(ren) become ill and a parent/guardian cannot be reached, please notify either of the following people:

Emergency Contact 1 Information

Full Name

Emergency Contact 2 Information

Full Name

Alternate Pickup Authorization

In the event that I/we are not able to pick up my/our child(ren), permission is given to leave with the following individual(s):

Authorization

I, the parent/guardian of the camper(s) listed on this form, authorize OSTNS to obtain immediate medical care and consents to the hospitalization of, the performance of necessary medical tests upon, the use of surgery on, and/or the administration of drugs to, my child(ren) or ward(s) if an emergency occurs when I can not be located immediately. It is also understood that this agreement covers those situations which are true emergencies and only when I cannot be reached. Otherwise, I expet to be notified immediately.

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Date of Signature

Date of Signature

Individual Camper Information

Camper 1

Full Name

Will Attend

Date of Birth

Camper 2 (if applicable)

Full Name

Will Attend

Date of Birth

Camper 3 (if applicable)

Full Name

Will Attend

Date of Birth

In order to secure your camper's spot, please submit a $100 NON-REFUNDABLE DEPOSIT PER CAMPER to Camp Kibbutz with your registration. Payment can be made online at https://ostns.org/donations_new.php or by check. Please include "Camp Kibbutz 2016 Deposit" in all payments and indicate name(s) of campers covered by deposit.