Fishers Montessori School, Inc. - Clay Montessori School

Fishers Montessori School, Inc.
Clay Montessori School
2018-2019 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
 




Full Member Schools of the American Montessori Society
 
 

 
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