Emergency Form (2020-2021 School Year)
Lighthouse Montessori School
Child’s Name: *
Date of Birth: *
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CHILD HAS FOLLOWING ALLERGIES: *
Mother’s Name: *
Mother’s Primary Phone #: *
Mother’s Alternative Phone #: *
Mother's Address: *
Mother's Email Address: *
Father’s Name: *
Father's Primary Phone #: *
Father’s Alternative Phone #: *
Father's Address: *
Father's Email Address: *
Additional Emergency Contacts #1 Name: *
Relationship with the Child: *
Phone #: *
Additional Emergency Contacts #2 Name:
Relationship with the Child:
Phone #:
Child's Physician's Name: *
Phone #: *
Child's Dentist's Name: *
Phone #: *
I hereby give consent to Lighthouse Montessori School to obtain ALL EMERGENCY MEDICAL OR DENTAL CARE prescribed by above duly License Physician (M.D.), osteopath (D.O.), or dentist (O.D.S.). *
Required
This form has been completed by ( Name of the parent or legal guardian) *
Relationship with the child: *
I have read and agreed with Lighthouse Montessori School Parent Handbook. *
Required
This form has been completed on the date: *
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