E - Emergency Information Form - Village Montessori School

Emergency Information Form

Student's Name *

First

Last

Birthdate *

Gender *

Home Address *

Home Phone *

Email *

Parent/Guardian 1 Name *

Parent/Guardian 1 Occupation *

Parent/Guardian 1 Cell Number *

Parent/Guardian 1 Work Number *

Parent/Guardian 2 Name *

Parent/Guardian 2 Occupation *

Parent/Guardian 2 Cell Number *

Parent/Guardian 2 Work Number *

Child's Doctor *

Doctor Phone Number *

Child's Dentist *

Dentist Phone Number *

Allergies *

Current Prescribed Medications *

Special Needs and Conditions *

If unable to reach parent/guardians, call *

If unable to reach parents/guardians call *

Person 1 authorized to pick up my child from school *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Person 2 authorized to pick up my child from school *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Additional persons authorized to pick up my child from school (address and phone number required) *

* Indicates required field

By typing my name below, I agree to the following statement: In the event of an emergency involving my child, and if Village Montessori School cannot get in touch with me, I hereby authorize any needed emergency medical care. I further agree to be fully responsible for all medical expenses incurred during the treatment of my child. *

By checking yes, I authorize my signature and agree to the terms and conditions above *

Yes

Submit