CLAY MONTESSORI SCHOOL - 463 E. Main Street      Carmel, Indiana 46032   (317) 580-1850
SUMMER CAMP 2017
Clay Montessori School
2017 Enrollment Form
(Form 2)

Child's Name:______________________     Birth Date: ____/_____/_______
Home address:_____________________     Phone: ____________________
                     ______________________      E-mail _____________________
Father's Name:_____________________     Work Phone:________________
Mother's Name:_____________________     Work Phone:________________
Person to call if Parents cannot be              Child's physician to be called in
reached in emergency:                               emergency:
Name:___________________________
Name:___________________________
Relationship:______________________       City:
Address:_________________________        Phone:
Address:_________________________
City:_____________________________       Hospital
Phone:___________________________
_________________________________

Allergies, medical conditions, fears, etc.___________________________________________________________________
______________________________________________________________________

Medical Release

I hereby give my consent to Fishers Montessori Schools, Inc. to administer first aid, authorize necessary emergency treatment at a nearby emergency hospital and/or authorize a medical doctor to examine or treat the above mentioned child while he/she is in attendance at Clay Montessori School/Fishers Montessori Schools, Inc. and on school related activities.  I further agree to accept the financial responsibilities for any costs incurred in treatment of any illness, accident or injury of the above named child.

X_____________________________________
Parent/Guardian Signature                       Date:

Person Authorized to Take Child From School

Name:________________________________
Relationship:___________________________
Name:________________________________
Relationship:___________________________
I am interested in forming a car pool:    Yes______   No______

Name of other driver: ______________________
Phone:__________________________________

I give my permission for my child to take part in all school activities including sports and school sponsored trips away from school premises and release the school from any and all liability to me or my child because of injury to my child during school or during off campus activity.

X_________________________________       _______________________
Parent/Guardian Signature                                Date:


Please visit the website of our parent company:

www.fishersmontessori.com


Full Member Schools of the American Montessori Society
Website Builder provided by  Vistaprint