A.student name *

First Name

Last Name

A.student home address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

A.student date of birth

MM

DD

YYYY

B.parent 1 name

First Name

Last Name

B.parent 1 address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

B.parent 1 home phone

(###)

###

####

B.parent 1 work phone

(###)

###

####

B.parent 1 cell phone

(###)

###

####

B.parent 2 name

First Name

Last Name

B.parent 2 home address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

B.parent 2 home phone

(###)

###

####

B.parent 2 work phone

(###)

###

####

B.parent 2 cell phone

(###)

###

####

contact 1 name

First Name

Last Name

contact 1 home phone

(###)

###

####

contact 1 work phone

(###)

###

####

contact 1 cell phone

(###)

###

####

contact 2 name

First Name

Last Name

contact 2 home phone

(###)

###

####

contact 2 work phone

(###)

###

####

contact 2 cell phone

(###)

###

####

child's doctor

First Name

Last Name

doctor phone

(###)

###

####

does your child have allergies

if yes, please list your child's allergies below

yes

no

child's dentist

First Name

Last Name

dentist phone

(###)

###

####

name 1

First Name

Last Name

name 1 home address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

name 1 work phone

(###)

###

####

name 1 home phone

(###)

###

####

name 1 cell phone

(###)

###

####

name 2

First Name

Last Name

name 2 home address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

name 2 work phone

(###)

###

####

name 2 home phone

(###)

###

####

name 2 cell phone

(###)

###

####

field trips

Parents will be notified of school field trip details in advance. If distance permits, students may walk as a group. It is understood that all reasonable caution will be taken by those persons in charge to prevent injuries, but neither those persons in charge nor the school shall be held legally responsible in case of an accident. I permit my child to participate in all student related activities, including school supervised field trips, while enrolled at MRM and give permission for appropriate faculty member(s) to authorize any emergency treatment that may be necessary.

yes

no

press releases and photo permission

Throughout the year, MRM produces a variety of publications about the school featuring our students. I permit photographs of my child to appear in both internal and/or external advertising and promotional materials related to MRM and that news of my child’s special accomplishments may be sent to the media.

yes

no

school directory

I permit my information (phone, address & email) to be published in the school directory.

yes

no

MRM staff

yes

no

parents of MRM students

yes

no

chartered buses

yes

no

EMERGENCY CARE

In case of an illness or accident: I give Many Rivers Montessori and its staff permission to provide any emergency care for my child that it deems necessary, including but without limitation to, calling a doctor for medical or surgical care, or to have my child taken to a hospital by ambulance. I understand that a conscientious effort will be made to locate me (and/or my partner) before any action will be taken. If it is not possible to locate us, this expense will be accepted by us. I agree to hold the program and its staff harmless from any liability resulting from any action or omission made in good faith resulting from said medical care. Indemnification: In consideration of the acceptance of my child as a student in this program, and having satisfied myself that supervision and attention to safety are prudent and reasonable, I agree to indemnify and hold harmless Many Rivers Montessori and its staff against all claims and demands made by or on behalf of my child, including through or by me, my spouse, or the legal guardian of the child.

I accept