SUMMER CAMP 2011
FISHERS MONTESSORI SCHOOL
Clay Montessori School
2011 Enrollment Form
(Form 2)
Child's Name:_________________ Birth Date ___/___/___
Home Address _________________ Phone: _______________
_________________
Father's Name: _______________ Work ph.______________
Mother's Name: _______________ Work ph.______________
Person to call if Parents Child's physician to be
cannot be reached in emergency: called in emergency:
Name _________________________ Name_________________
Relationship ____________________ Address_______________
Address _______________________ City __________________
City __________________________ Phone ________________
Phone ________________________ Hospital _______________
Allergies, Medical conditions, fears, etc.______________________________________________________
Medical Release
I hereby give my consent to Fishers Montessori Schools, Inc. to administer first aid, authorize necessary emergency treatment at a nearby emergency hospita and/or authorize a medical doctor to examine or treat the above mentioned child while he/she is in attendance a Fishers Montessori Schools, Inc. and on school related activities. I further agree to accept the financial responsibilities for any costs incurred in treatment of any illness, accident or injury of the above named child.
X__________________________ _______________________
Parent/Guardian Signature Date
Person Authorized to Take Child From School
Name:___________________ Relationship:___________________
Name:___________________ Relationship:___________________
I am interested in forming a car pool: Yes____ No____
Name of other driver:_______________ Phone:________________
I give my permission for my child to take part in all school activities including sports and school sponsored trips away from school premises and release the school from any and all liability to me or my child because of injury to my child during school or during any off campus activity.
X__________________________ _______________________
Parent/Guardian Signature Date
