Fishers Montessori Schools, Inc.
Clay Montessori School
2011-2012 Enrollment Form
Child’s Name: _________________________ Birth Date: _____/______/____
Home Address:_________________________ Phone No.: __________________
__________________________
Father’s Name: _________________________ Work Phone: _________________
Mother’s Name: ________________________ Work Phone: _________________
Person to call if Parents cannot be Child’s Physician to be called in an
Reached in an Emergency: 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 hospital and/or authorize a medical doctor to examine or treat the above mentioned child while he/she is in attendance at Fishers Montessori Schools, Inc. and on school related off campus activities. I further agree to accept the financial responsibilities for any costs incurred in the treatment of any illness, accident or injury of the above named child.
X_________________________________ _____________________________
Parent/Guardian Date
PERSON AUTHORIZED TO TAKE CHILD FROM SCHOOL
NAME:__________________________ RELATIONSHIP:_____________________
NAME:__________________________ RELATIONSHIP:_____________________
I am interested in forming a carpool: 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 the school premises and release the school from any and all liability to me or my child because of injury to my child at school or during any off campus activity.
X__________________________________ _____________________________
Parent/Guardian Date
Affiliate Schools of the American Montessori Society
