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The Mountain School Admission Form

Child's Name(Required)

Child's Birthday

Month

Day

Year

Primary Caregiver Information

First Name(Required)

Last name(Required)

Relationship to Child

Place of Employment

Email(Required)

Cell Phone(Required)

Work Phone

How do you prefer to be contacted?

Email

Cell phone

Work phone

Secondary Caregiver Information

Name

Relationship to Child

Place of Employment

Email

Cell Phone

Work Phone

How do you prefer to be contacted?

Email

Cell phone

Work phone

Emergency Contact Information

1st Emergency Contact Name (Required)

1st Emergency Contact Phone(Required)

Address

2nd Emergency Contact Name

2nd Emergency Contact Phone

Address

3rd Emergency Contact/Phone

Address

Other people allowed to pick-up child from childcare

1st Contact Name(Required)

1st Contact Phone(Required)

Address

2nd Contact/Phone

Address

3rd Contact/Phone

Address

Doctor/Hospital/Dentist Information

Child's Doctor Name(Required)

Child's Doctor Phone Number(Required)

Address

Child's Hospital of Choice Name(Required)

Child's Hospital of Choice Phone Number(Required)

Address

Child's Dentist Name(Required)

Child's Dentist Phone Number(Required)

Address

Emergency Medical Treatment

In the case of an emergency, the Mountain School has authorization to provide Emergency Medical Treatment and transport of your child to the hospital of choice. If there is an objection to this, a written statement giving the reason will be provided.(Required)

Yes

Helpful information about your child

List any known allergies(Required)

Please share favorite hobbies/sports/crafts your child likes to do and any concerns that might be helpful for the Mountain School team to know.

List siblings and ages

Sunscreen Authorization

Does the Mountain School have authorization to use sunscreen for your student?(Required)

Yes

No

If no, specify what sunscreen you will provide.

Field Studies Authorization

Does the Mountain School have authorization to take your student on field studies?(Required)

Yes

No

Media Authorization

Does the Mountain School have authorization to publish photos of your student on social media outlets, most often the Mountain School website, which is a managed community of local families?(Required)

Yes

No

Opt-Out Scheduled Activities

Please let us know if there is any activity your child should not participate in.

Media and Internet Usage Plan

In the rare event that we use media and internet for our program, access is only for child age searches and viewing. We teach safe online practices and use the internet to show short educational videos. Please let us know if you have any questions.

Attendance Dates Desired

Please include start date. ex. “Monday through Friday from June 10th to August 16th (47 total days)” or: “Mondays, Tuesdays, Wednesdays from June 10th to August 16th (30 total days)”

Today's Date

Month

Day

Year

Signature(Required)

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Subscribe Form

Thanks for submitting!

bencanady7@gmail.com

123-456-7890

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