Emergency Form EMERGENCY FORMSTUDENT NAME First Last BIRTHDAY Date Format: MM slash DD slash YYYY FATHER NAME First Last CELL PHONEWORK PHONEE-MAIL WORK ADDRESSMOTHER NAME First Last CELL PHONEWORK PHONEE-MAIL WORK ADDRESSALLERGIES?ALTERNATE CONTACTS in case of emergency(These should be adults you trust, who your child knows well, able to communicate in English, available locally and who can be reached in an emergency to pick up your child from school and provide the needed care for your child.)ALTERNATE CONTACT #1NAMETELEPHONEALTERNATE CONTACT #2NAMETELEPHONECHILD/FAMILY DOCTORNAMEPHONEADDRESS CHILD/FAMILY DENTISTNAMEPHONEADDRESS STUDENT MEDICAL TREATMENT PERMISSIONPLEASE CHECK THE BOX BESIDE THE STATEMENT I authorize The Montessori House to refer my child for treatment to the school physicians in the event of an accident or sudden illness where the above-listed parents, alternate contacts, and child’s doctor, cannot be timely reached by phone. The school physicians are Tenafly Pediatrics and they use Englewood Hospital. Authorized by:PARENT SIGNATUREDate Date Format: MM slash DD slash YYYY STUDENT PICTURE RELEASEPLEASE CHECK THE BOX BESIDE THE STATEMENT By signing this release, I grant to The Montessori House the rights to display, use, publish, transfer, exhibit, and variously disseminate in any media photographic images of my child or her/his parents in conjunction with newsletters, information, education, advertising and public relations efforts on behalf of the school or the Montessori Method of education. Concerning photographs of my minor children, I warrant that I am the parent or legal guardian with authority to sign this release on their behalf. Please check only one:ACCEPT STUDENT PICTURE RELEASEDECLINE STUDENT PICTURE RELEASEAuthorized by:PARENT SIGNATUREDate Date Format: MM slash DD slash YYYY
