Student Information & Permissions Form

Child's First Name

Child's Last Name

Child's Date of Birth

Child's Teacher

Home Phone

Student(s) Email

Student's Home Address

Student's Home Address 2

Student's City

Student's State

Student's Zip

List any siblings NOT attending WHMS

Parent Marital Status

Parent 1 First Name

Parent 1 Last Name

Parent 1 Home Phone (If different)

Parent 1 Home Address 2 (If Different)

Parent 1 City

Parent 1 State

Parent 1 Zip

Parent 1 Cell Phone

Parent 1 Place of Employment

Parent 1 Occupation

Parent 1 Business Phone

Parent 1 Email

Parent 2 First Name

Parent 2 Last Name

Parent 2 Home Address (If Different)

Parent 2 Home Address 2 (If Different)

Parent 2 City

Parent 2 State

Parent 2 Zip

Parent 2 Home Phone (If different)

Parent 2 Cell Phone

Parent 2 Place of Employment

Parent 2 Occupation

Parent 2 Business Phone

Parent 2 Email

Child's Public School District

Transportation AM

Transportation PM

Name of Authorized Pick Up (Other than parent)

Phone of Authorized Pick Up (Other than parent)

Relationship to student

Name of Authorized Pick Up (Other than parent)

Phone of Authorized Pick Up (Other than parent)

Relationship to student

Grandparent 1 First Name

Grandparent 1 Last Name

Grandparent 1 Street Address

Grandparent 1 City

Grandparent 1 State

Grandparent 1 Zip Code

Grandparent 2 First Name

Grandparent 2 Last Name

Grandparent 2 Street Address

Grandparent 2 City

Grandparent 2 State

Grandparent 2 Zip Code

Family Doctor Name

Family Doctor Phone #

Does your child have any allergies? (Excludes seasonal) If yes, please complete an Allergy Action Plan

Yes

No

Early & Emergency Dismissal

I permit WHMS to send my child home on the bus, even if I cannot be reached

I permit WHMS to send my child home on the bus, only if I am contacted

I will pick my child up at WHMS by 3pm

Early & Emergency Dismissal - Snow days will be announced on local radio and TV stations. WHMS is listed as Woodland Hill Montessori School; we do not follow East Greenbush CSD closing and dismissals.

Emergency Contact Name

Please list your emergency contacts in the event of an early dismissal or emergency notification, if you can't be reached.

Emergency Contact Home Phone

Emergency Contact Cell Phone

Parents will be notified of school field trip details in advance. If distance permits, students may walk as a group. It is understood that all reasonable caution will be taken by those persons in charge to prevent injuries, but neither those persons in charge nor the school shall be held legally responsible in case of an accident.

I permit my child to ride in the cars of WHMS parents:

No

Yes

I permit my child to ride in the cars of WHMS faculty:

No

Yes

I permit my child to ride on school chartered buses:

No

Yes

I permit photographs of my child to appear in both internal and/or external advertising and promotional materials related to WHMS and that news of my child's special accomplishments may be sent to the media:

No

Yes

Your name, address, email, and home phone number, as listed on this form, will be included in the school directory, dispersed only to current enrolled families for the purpose of communication. Many families use the directory to coordinate social events and birthday parties. Your contact information will not be shared with or sold to any third party vendors or used for the purpose of solicitation. If you wish to opt out of the school directory, please indicate your preference below.

School Directory - Opt Out ONLY

Please do NOT publish any contact information in the school directory

Parent 1 Address ONLY

Parent 1 Email ONLY

Parent 1 Home Phone ONLY

Parent 2 Address ONLY

Parent 2 Email ONLY

Parent 2 Home Phone ONLY

Name of Person Completing this Form

4 * 3 is