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Arlington Montessori House

3809 Washington Boulevard
Arlington, VA, 22201
United States

703.524.2511

Emergency Care Form

EMERGENCY CARE & RELEASE FORM

Name of Student *
Name of Student
Address *
Address
Home Phone *
Home Phone
Parent 1 Name *
Parent 1 Name
Parent 1 Cell *
Parent 1 Cell
Parent 1 Work *
Parent 1 Work
Parent 2 Name *
Parent 2 Name
Parent 2 Cell *
Parent 2 Cell
Parent 2 Work *
Parent 2 Work
AMH Health Policy *
The school will notify the parents if your child has an emergency or becomes ill. Children will not be allowed to attend or will need to be excluded if any of the following symptoms occur: A temperature over 100 degrees Any recurring vomiting or diarrhea Or has any signs of other communicable illness
Consent for Medical Attention *
Alternative Emergency Contact *
Alternative Emergency Contact
When I/we am/are not able to be reached in the event of an emergency, I/we give authorization to contact the following:
Cell Phone *
Cell Phone
General Release Contact 1 *
General Release Contact 1
Phone *
Phone
General Release Contact 2
General Release Contact 2
Phone
Phone
General Release Contact 3
General Release Contact 3
Phone
Phone
Contact outside of the metropolitan area
Contact outside of the metropolitan area
Phone
Phone
**FORM EXPIRES ONE YEAR FROM THIS DATE