Fishers Montessori School, Inc. - Clay Montessori School
Clay Montessori School
2019 Enrollment Form
(Form 2)
Child's Name:_________________  Birth Date ___/___/___
Home Address _________________  Phone: _______________
             _________________  E-mail_________________
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 hospital 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
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