Emergency Contact & Authorization Form

Emergency Contact & Authorization Form
Your Name*
Your Email*
example@example.com
Please Enter Your Child's Information Here
First Name
Middle Name
Last Name
Age
Gender*
Date of Birth*

MonthDayYear
Date
Phone Number*

######-####
Child's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
The following persons are authorized to pick-up my child.

You may enter multiple names per box separated by a comma.
ARRANGEMENTS FOR CONTACTING PARENTS IN THE CASE OF AN EMERGENCY

Please List In Order You Would Like Us To Call
Parent 1*

First NameLast Name
Phone Number*

Area CodePhone Number
Alternate Phone

Area CodePhone Number
Parent 2*

First NameLast Name
Phone Number*

Area CodePhone Number
Alternate Phone

Area CodePhone Number
IF NEITHER PARENT CAN BE REACHED, IN THE CASE OF EMERGENCY CALL:
Alternate Contact 1*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship
Alternate Contact 2*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship
Child's Doctor*

First NameLast Name
Doctor's Office Number*

Area CodePhone Number
Office Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's Dentist*

First NameLast Name
Dentist's Office Number*

Area CodePhone Number
Office Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Allergies*
If none, please type "None"
Special Problems
Insurance Company*
Policy #*
I hereby authorize the staff of Montessori Education Center of Hawaii to arrange transportation in case of accident or acute illness of my child. In the event that it is impossible to receive instruction from either parent for my child’s care, consent is given to any licensed physician and/or surgeon called or to whom my child is taken, for treatment by him or to administer drugs or medication, and to perform such surgical treatment as he shall think the existing emergency requires for the relief of pain and/or the preservation of my child’s life, and/or health and well-being. I shall pay any cost incurred in this connection not covered by my insurance.I also give my permission for my child to attend occasional walks and field trips away from the school site. I understand notices will be sent home in advance of field trips (not walks). I further understand that staff members and/or parents may transport the children and that each child will ride in their own car seat furnished by parent.*

I Authorize
Should be Empty: