Parent/Guardian Student Emergency Profile Student Emergency Profile Step 1 of 4 25% Parent/Guardian Name(Required) First Last Parent/Guardian Primary Email Address(Required) Parent/Guardian Primary Phone Number(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Would you like to add an additional parent/guardian contact to your account?(Required) Yes No Additional Parent/Guardian Name First Last Additional Parent/Guardian Email Address Additional Parent/Guardian Phone NumberAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Student Emergency ProfileStudent Name(Required) First Last Date of Birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Does your child have any allergies or sensitivities?(Required) Yes No If yes, what are their reaction(s) and treatment plan(s)?(Required)What is the name for your child's primary care physician?(Required) First Last What is your child's primary care physician's phone number?(Required)Would you like to add another student emergency profile to your account?(Required) Yes No Student Name(Required) First Last Date of Birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Does your child have any allergies/sensitivities?(Required) Yes No If yes, what are their reaction(s) and treatment plan(s)?(Required)What is the name for your child's primary care physician?(Required) First Last What is your child's primary care physician's phone number?(Required) Who may pick up your child(ren) from school?Name(Required) First Last Phone(Required)Name First Last PhoneName First Last PhoneName First Last PhoneName First Last Phone Consent & AcknowledgementI do hereby authorize emergency medical care and consent for my child(ren)'s primary care physician to be contacted in case of emergency:(Required) Yes No Guardian Signature(Required)I give permission for photos/videos of my child to be taken for school purposes (school newsletters and flyers, social media/website posts, etc.). Note: Children's names are never associated with their image.(Required) Yes No Guardian Signature(Required)I give permission for the following information to be included in the student directory:(Required) Primary Guardian Name Primary Guardian Mailing Address Primary Guardian Phone Number Primary Guardian Email Address Additional Guardian Name Additional Guardian Mailing List Additional Guardian Phone Number Additional Guardian Email Address Deselect AllGuardian Signature(Required)I have read the Little River Montessori School Parent Handbook.(Required) Yes Guardian Signature(Required)I have received a copy of the Tennessee Department of Education Summary of Child Care Approval Requirements.(Required) Yes Guardian Signature(Required)
