Person(s) Authorized to Pick Up Child (other than parent/guardian listed above)
Alternate Person(s) to Call in Case of an Emergency
Out of Province Contact Person Please list at least one out of province contact. Note: this person will be contacted if there are no local telephone services due to a natural disaster.
Emergency Health Information
Consent for Emergency Care
In the event that my child is injured, ill or in need of immediate attention I, authorize the staff of North Fleetwood Montessori School to seek medical attention and/or admit my child to hospital if I am unable to be contacted or otherwise unable to respond.
Child’s Immunization Status (Please record dates [year/month/day] or attach copy of immunizations)
Family and General Household Information
Parent/Guardian Providing Information