Student Information Card

STUDENT INFORMATION CARD
Student Name
First Last
Address
Street Address City ZIP / Postal Code
Age
Birthday
Date Format: MM slash DD slash YYYY
Parent 1 Name
First Last
Parent 1 Profession
Parent 1 Place of Employment
Home Phone #
Work Phone #
Cell Phone #
Parent 1 Email Address
Parent 2 Name
First Last
Parent 2 Profession
Parent 2 Place of Employment
Home Phone #
Work Phone #
Cell Phone #
Parent 2 Email Address
EMERGENCY INFORMATION
Physician’s Name
Office Phone #
Dentist’s Name
Office Phone #
Hospital preferred
Allergies or other medical information
Insurance company
Policy ID#
Name of person(s) to contact in case of emergency if parents are unavailable:
Emergency Contact #1
Name Phone # Relationship to family Address
Emergency Contact #2
Name Phone # Relationship to family Address
Emergency Permissions:
- I give Grace Montessori School permission to seek medical care for my child.
Signature
Date
Date Format: MM slash DD slash YYYY

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Grace Montessori School