Apple Blossom Cottage

A Montessori Pre-school

Student Information and Medical Form

Child’s Name:_________________________________________________________ Sex: Male Female

Child’s Date of Birth____________________________ Telephone:______________________________

Address:_____________________________________ City:______________________ State:_________

Mother/Guardian:____________________________________ Cell Phone:________________________

Employer:____________________________________ Work Phone:_______________________

E-mail:________________________________________________________________________

Father/Guardian:_____________________________________ Cell Phone:________________________

Employer:____________________________________ Work Phone:_______________________

How did you hear about this school? ______________________________ Parent Helper? Yes No

What are the goals for your child in this class? _______________________________________________

_____________________________________________________________________________________

Siblings and their ages:__________________________________________________________________

_____________________________________________________________________________________

Describe any medical problems or special needs I should be aware of and how you would like me to take

care of them while they are here:__________________________________________________________

_____________________________________________________________________________________

Persons designated to pick up your child and call in an emergency:

Name Relation to child Phone Number Cell Number

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Child’s Physician:________________________________________ Phone Number:_________________

Child’s Dentist:__________________________________________ Phone Number:________________

In case of serious emergency or illness, when the parents cannot be reached immediately, I hereby
authorize the child care provider to obtain emergency medical care.

Insurance Company:_____________________________________ Insurance Number:_______________

Signature of Parent or Guardian:__________________________________________ Date:____________