Emergency Release Form-Purcellville Montessori Step 1 of 3 33% 2020/2021 Emergency Release FormName of ChildBirth Date Date Format: MM slash DD slash YYYY Parent’s NameParent’s Address Street Address City State / Province / Region ZIP / Postal Code Parent’s E-mail address Home PhoneMother’s Cell phoneFather's Cell phoneFather’s OccupationBusiness Phone (Father’s)Business AddressMother’s OccuptionBusiness Phone (Mother’s)Business Address EMERGENCY CONTACTS: (Other than Parents)NameHome PhoneWork PhoneNameHome PhoneWork Phone Insurance CompanyPolicy NumberName of Child’s PhyscianPhoneAddressName of Child’s DentistPhoneIn the event of sickness or an accident if the parents, guardian, your physician or your dentist cannot be reached, may we use our physician or dentist? And or the nearest hospital?Any special allergies/problems?Allergic to any medication?Symptoms of AllergyThe following individuals are pre-authorized to pick up my child at any time (include family members, friends, nanny, etc)Check the box beside the statement: The Montessori School of Leesburg has my permission in an emergency, when I or my physician or dentist cannot be contacted to take my child to the nearest emergency room or nearest hospital or dental office. The dentist or hospital staff has my permission and authority to give emergency care when a physician deems it necessary for the well being of the child. I understand that I am responsible for all costs that may occur in providing my child with needed emergency care due to an illness or an accident on school premises. I am also responsible for all hospital, medical and or dental bills for long term care due to an illness or accident on school premises. I understand that the school is not financially responsible for any hospital, ambulance, medical or dental care of my child. Parent or Guardian SignatureParent or Guardian SignatureDate Date Format: MM slash DD slash YYYY
