To Whom It May Concern:

I hereby authorize the bearer, who is a staff member of Cross of Life Christian Montessori, to sign any forms required in order to admit my child,

________________________________________                                    __________________________________
                            Child’s full name                                                                                  Date Of Birth

to emergency treatment at the nearest facility.  I do so in order to ensure that my child may receive prompt medical attention in case of emergency when I cannot reach the facility promptly.

I certify that I will be liable for all medical and hospital expenses incurred in this regard.


___________________________________               _____________________________________________          _____________________
         Parent or Guardian Name Printed                             Signature of parent or guardian                             Date


MEDICAL & ALLERGY INFORMATION (please continue on back if needed)

1. Does your child use any type of medication on a regular basis? If so, what medication and dose:

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2. Please list all allergies & associated symptoms:

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If exposure to the allergen occurs, does your child immediately require medication (antihistamines and/or
epinephrine)?_____ If yes, your physician must complete the Allergy Action Plan for each allergen. Copies are
available in the office.

3. Does your child have any food intolerances or personal/religious dietary restrictions?

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4. Has your child had any serious accidents/injuries? (if yes, list date)

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5. Does your child have any chronic illness or disability of which we should be aware?

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