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SHM Emergency Contact Form

This document is an emergency contact and pick up form for Stuyvesant Heights Montessori. It requests contact information for the child's parents/guardians, emergency contacts if parents cannot be reached, and authorized pick up persons. It also requests medical information including allergies, physicians, and medications. It notes that periodic short neighborhood walks will be taken with proper supervision and parents must grant permission for their child to attend walks by signing the form.

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shmontessori
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143 views1 page

SHM Emergency Contact Form

This document is an emergency contact and pick up form for Stuyvesant Heights Montessori. It requests contact information for the child's parents/guardians, emergency contacts if parents cannot be reached, and authorized pick up persons. It also requests medical information including allergies, physicians, and medications. It notes that periodic short neighborhood walks will be taken with proper supervision and parents must grant permission for their child to attend walks by signing the form.

Uploaded by

shmontessori
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Stuyvesant Heights Montessori Emergency Contact & Pick Up Form

Child’s Name Birthdate

Address Home phone

Mothers /Guardians Information Fathers/ Guardians information

Mother’ Name Fathers’ Name

Cell Phone Cell Phone

Email Email

Work Phone Work Phone

If we are unable to reach the parents, we will attempt to reach a neighbor, relative or friend who will assume responsibility for care of the
child in an emergency.

Name Phone Number

Relationship Address

Name Phone Number

Relationship Address

Name Phone Number

Relationship Address

Names of persons (other than parents) AUTHORIZED to take the child from school. Include any carpool arrangements:

Name Phone Number

Name Phone Number

Name Phone Number

Name Phone Number

In due time at least ONE person on this list must be a parent to a child that already attends SHM and is apart of the buddy system.

Pick Up Buddy/Parent Name Phone Number Buddy’s Class

LIST ANY KNOWN ALLERGIES / RESTRICTIONS:(if none state none)

Physicians Name Phone Number

Physicians Address

Medical Insurance Carrier: ID# Group#

History of any physical or medical problems:

Special Disabilities(if any):

Is your child currently taking any medications? If yes, state type & reason:

Periodic short neighborhood walks will be taken from the school into the community. Sometimes we will walk to Saratoga Park located on Howard
Avenue between Macon Street. Proper Adult supervision is provided on all short walks outside of the school. We also leave the Premises for fire
drills. Stuyvesant Heights Montessori (teachers/director) reserve the right to determine it is safe for a child to go on outside walks. In the event that it
is not safe for a child to go on walks they will stay in another classroom until their class returns.
I grant my child _________________________________ to attend short neighborhood walks.

Parents Signature___________________________________________________ Date__________________________

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