Home
About Us
Programme
Gallery
Locations
Contact
Blog
Online Application
Ask a Question
Medical Form
Step 1 of 3 - Medical Information
0%
Name of Pediatrician
*
First
Last
Name of Doctor
*
First
Last
Telephone Number
*
Medical Aid Number
*
Any Allergies And Reaction
Test/Evaluations
Name of Parent
First
Last
Name and Telephone number of a person/s who can be contacted in a case of emergency
Emergency Contact Details
Name of a person/s who can be contacted in a case of emergency
First
Last
Telephone Number
Telephone number of a person/s who can be contacted in a case of emergency
Consent
*
I hereby authorise the principle, teachers, or assistants to seek any medical attection/advice, which my child may require, when the Paediatrician/Family Doctor or ourselves cannot be contacted.
I undertake that I shall be responsible for, and shall make payment of, any and all medical fees and/or costs
incurred in obtaining medical attention / advice for my child.
I agree to the privacy policy.
Consent and Indemnity
In favour of Littlehill Montessori Pre-school (The Pre-school)
Name
*
First
Last
ID Number
*
Please enter a number from
12
to
12
.
Physical Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
The Mother/Guardian
First
Last
The Father/Guardian
First
Last
Name Of Parent(s) and/or Guardian
First
Last
Witness
First
Last
date placed
Date Format: MM slash DD slash YYYY
Consent
*
Hereby give consent for my son or daughter to take part in any activities of the Pre-School including off site excursions and extra murals while on the Pre-School premises or any such place where such activities are engaged in, and to make use of the educational and play equipment at the Pre-School.
I fully understand and accept that all Pre-School activities of the Pre-School shall be undertaken at my son/daughter and my owner risk and I undertake on behalf of myself, the executor or my estate, my spouse, and my child aforesaid, to indemnify, hold harmless and above the Pre-School, the owner, principal, teachers and paid or unpaid assistants against and from any claims whatsoever that may arise in connection with any loss and damage to the property, or injury, illness or death to the person of my child aforesaid in the course of an excursion or Pre-School activity not withstanding that the owner, principal, teachers and paid or unpaid assistants will nevertheless take all reasonable precautions for the safety and welfare of my child.
I have read and understood the terms and conditions
Protection Of Personal Information
Child's Name
First
Last
Name of Parent/Guardian
First
Last
Relation to Student
*
--Please Select--
Parent
Guardian
Mentor
Consent
*
Indemnity and Consent Form
_______________________________
We are sending you this parental consent form to both inform you and to request permission for your child’s photo/image and personally identifiable information to be published on the school’s website/Facebook page/Instagram account/advertisement.
Global access to the Internet does not allow the school to control who may access information posted on the above social and print media platforms. We as schools do want to celebrate your child and his/her work. The law requires that we ask for your permission to use information about your child.
Pursuant to law, the school will not release any personally identifiable information without prior written consent from you as parent or guardian.
Personally identifiable information includes student names, photo or image and locations and times of class trips.
If you, as the parent or guardian, wish to rescind this agreement, you may do so at any time in writing by sending a letter to the principal of Littlehill Montessori and such rescission will take effect upon receipt by the school.
I grant / do not grant permission for a photo/image that includes my child/ren without any other personal identifiers to be published on the school Internet site/Facebook page/Instagram account/advertisement.
I grant / do not grant permission for my child/ren’s photo/image and name to be published on the school website/Facebook page/Instagram account/advertisement.
I/We grant / do not grant permission for my child/ren’s photo/image and all other personal identifiers
listed above to be published on the school /Facebook page/Twitter account/advertisement.
I have read and understood the terms and conditions
Phone
This field is for validation purposes and should be left unchanged.
This iframe contains the logic required to handle Ajax powered Gravity Forms.