Woodside Montessori Academy Summer Program Emergency Information Form

Emergency Information Form 2220
Name*

Student's NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Alternate Phone

Area CodePhone Number
Miscellaneous Information:
Guardian/Nanny/Caregiver's Name & Phone Number
Parent Work Information and EMERGENCY Contacts
Please check*

I hereby authorize Woodside Montessori Academy to provide first aid and/or permit emergency first aid treatment for my child. Woodside is further authorized to provide for transportation of my child to the nearest hospital as it may be deemed necessary.
Parent Name*

First NameLast Name
Cell Phone*

Area CodePhone Number
Work Phone

Area CodePhone Number
Email
example@example.com
Parent Name

First NameLast Name
Cell Phone

Area CodePhone Number
Work Phone

Area CodeEmail
Email
example@example.com
please check*

When unable to reach me in case of illness or emergency, I hereby authorize the school to contact the following persons: (please provide at least one alternate contact and phone number)
Emergency Contact 1*

First NameLast Name
Phone Number*

Area CodePhone Number
Phone Number

Area CodePhone Number
Emergency Contact 2

First NameLast Name
Phone Number

Area CodePhone Number
Phone Number

Area CodePhone Number
Emergency Contact 3

First NameLast Name
Phone Number

Area CodePhone Number
Phone Number

Area CodePhone Number
I give permission to Woodside Montessori Academy to contact the child's doctor or dentist in an emergency:
I give permission to Woodside Montessori Academy to contact the child's doctor or dentist in an emergency: *
Physician Name
Physician's phone Number

Area CodePhone Number
Dentist Name
Dentist's Phone Number

Area CodePhone Number
Personal Physical Attributes
Age*
Sex:*
Hair Color*
Height*
Weight*
Eye color *
T-shirt size*
Allergies/ chronic medial condition (please put n/a if not applicable)*
Identifying Features
Siblings

NameAge
NameAge
NameAge
Persons Authorized to Pick-Up My Child
My Child will arrive at the program:*

Parent (other caretaker) Drop OffOther
My Child will depart from the program:*

Parent (other caretaker) Pick UpOther
For daily dismissal I hereby authorize that my child to be released to only the following designated people: (Include both parents is applicable) AT LEAST ONE ALTERNATE PERSON MUCH BE DESIGNATED.*

Please check to acknowledge you've read this
First Pick Up*

First Name (appears on driver's license)Last Name
Second Pick Up*

First Name (appears on driver's license)Last Name
Third Pick Up

First Name (appears on driver's license)Last Name
Fourth Pick Up

First Name (appears on driver's license)Last Name
Fifth Pick Up

First Name (appears on driver's license)Last Name
Sixth Pick Up

First Name (appears on driver's license)Last Name
Name

First Name (appears on driver's license)Last Name
I understand that Woodside Montessori Academy offers a variety of integrated learning experiences, which may include walks off the premises. I heregby give permission for my child to participate in all outdoor activies on and off the premises.
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

Emergency Information Form 2220

Parent Work Information and EMERGENCY Contacts

Personal Physical Attributes

Persons Authorized to Pick-Up My Child