(Please write clearly and answer every question. If the answer is NONE please write NONE.)
For mailing purposes (if different from above):
Please list the NAME and CONTACT INFORMATION of the person whom you would like contacted in the event of an emergency.
What medical insurance do you have?
I hearby authorize others to seek appropriate medical treatment on my behalf in the event of an emergency should I become incapacitated.
PO Box 68, Rockport, ME 04856 / Phone: 207-236-6316 / E-FAX: 207-470-1024Email: email@example.com / www.nemontessori.org