Emergency Form
Lighthouse Montessori School (2019-2020 School Year)
Child’s Name: *
Your answer
Date of Birth: *
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CHILD HAS FOLLOWING ALLERGIES: *
Your answer
Mother’s Name: *
Your answer
Mother’s Primary Phone #: *
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Mother’s Alternative Phone #: *
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Mother's Address: *
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Mother's Email Address: *
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Father’s Name: *
Your answer
Father's Primary Phone #: *
Your answer
Father’s Alternative Phone #: *
Your answer
Father's Address: *
Your answer
Father's Email Address: *
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Additional Emergency Contacts #1 Name: *
Your answer
Relationship with the Child: *
Your answer
Phone #: *
Your answer
Additional Emergency Contacts #2 Name:
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Relationship with the Child:
Your answer
Phone #:
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Child's Physician's Name: *
Your answer
Phone #: *
Your answer
Child's Dentist's Name: *
Your answer
Phone #: *
Your answer
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) *
Your answer
Relationship with the child: *
I have read and agreed with Lighthouse Montessori School 2019-2020 School Year Parent Handbook. *
Required
This form has been completed on the date: *
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