* = Required Information
Monday Tuesday Wednesday
Thursday Friday

Student Information

Male Female

Parent/Guardian Information

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)

Yes, immunized No, not immunized

Health Information

Yes No

Developmental Area

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Family and General Household Information

Parent/Guardian Providing Information