E - Emergency Information Form - Village Montessori School

Emergency Information Form

* Indicates required field

Student's Name: *

First

Last

Birthdate: *

Gender: *

Female Male

Home Address: *

City, State Zip *

Parent/Guardian 1 Name: *

Parent/Guardian 1 Cell Number: *

Parent/Guardian 1 Email: *

Parent/Guardian 1 Occupation: *

Parent/Guardian 2 Name: *

Parent/Guardian 2 Cell Number: *

Parent/Guardian 2 Email: *

Parent/Guardian 2 Occupation: *

Primary Insurance Company: *

Name of Insured: *

Doctor's Address: *

Policy #/Group #: *

Child's Doctor: *

Doctor's telephone number: *

Child's Dentist: *

Dentist's telephone number: *

Preferred Hospital: *

Allergies: *

Current Prescribed Medications: *

Special Needs and Conditions: *

If unable to reach parent/guardians, call: *

Person 1 authorized to pick up my child from school: *

First

Last

Person 2 authorized to pick up my child from school: *

First

Last

Address *

Phone Number *

Address *

Phone Number *

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.

Parent/Guardian Name *

Date *

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

Yes

Submit