WOM Children's House: Emergency Info and Authorized Pick-up Form 2019-2020
Student's Last Name *
Your answer
Student's First Name *
Your answer
Student's Date of Birth *
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DD
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YYYY
Allergies/Medical Conditions
Please list all known allergies and/or medical conditions below and provide medical documentation that can be reviewed by Willow Oak Montessori administration.​ ​Do not leave blank, indicate none/none known.​ ​If allergies or medical conditions are severe--additional information & planning will be needed.
Allergies? *
Your answer
Medical Conditions? *
Your answer
Daily Medications or Other Special Needs/Considerations? *
Your answer
Has your child had any head injury/concussion in the past year? If yes, please provide details below *
Your answer
Emergency Contact Information
First Person to contact in an emergency, NAME *
Your answer
Relationship to student *
Your answer
Preferred method of contact, provide info for texting, calling or email. *
Your answer
Second Person to contact in an emergency, NAME *
Your answer
Relationship to student *
Your answer
Preferred method of contact, provide info for texting, calling or email *
Your answer
Medical Treatment Authorization
In the event of illness or injury, I hereby authorize Willow Oak Montessori staff to administer first aid to my child and to obtain emergency medical treatment for my child, including administration of an anesthetic or other medication and surgery, and I hereby assume the cost of such treatment. I understand that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, but is given to provide authority and power on the part of Willow Oak Montessori to give specific consent to the diagnosis, treatment, or hospital care which in the best judgment of a licensed physician is deemed advisable. I understand that Willow Oak Montessori staff will make best efforts to notify me immediately should emergency treatment for my child become necessary. I also grant permission for emergency CPR to be administered to my child should it become necessary.

Authorized Release of Child
Willow Oak Montessori staff will not release your child to anyone other than his/her guardian(s) and any individual specified below or in writing by you at a future date. Proper identification will be required when the child is picked up.
Authorized Person 1
Your answer
Authorized Person 2
Your answer
Authorized Person 3
Your answer
Authorized Person 4
Your answer
Authorized Person 5
Your answer
Authorized Person 6
Your answer
Please notify the school promptly regarding any changes to the information provided on this form.
By inserting my full name below, I agree with the statements herein and affirm the information I have provided is correct. I am the parent/legal guardian of the student named above. *
Your answer
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