STUDENT FORMS 2016-2017

Child's Name *
Child's Name
Date of Birth *
Date of Birth
Guardian 1 *
Guardian 1
Address *
Address
Cell Phone *
Cell Phone
Home Phone
Home Phone
Work Phone
Work Phone
Guardian 2
Guardian 2
Address
Address
Cell Phone
Cell Phone
Home Phone
Home Phone
Work Phone
Work Phone
Emergency Contact 1 *
Emergency Contact 1
Must live within 1/2 hour of the school
Contact Phone *
Contact Phone
Emergency Contact 2 *
Emergency Contact 2
Must live within 1/2 hour of the school
Contact Phone *
Contact Phone
Physician
Physician
Physician Phone
Physician Phone
Medical Transport *
I understand that in case of a medical emergency, my child may need to be transferred to the nearest hospital or outpatient facility. In an urgent situation, Primrose Hill School may need to contact local emergency services before contacting parents for guardians. If a child is ill or injured or in the ever of an evacuation, the above individuals may be contacted and have permission to transport my child.
The following individuals have permission to pick up my child:
Media Waiver *
Primrose Hill School relies on digital and print media to promote the school and your participation is very much appreciated! Please note we are extremely discerning about the use of images in our marketing. By checking “I ACCEPT,” you hereby consent to allow the use of voice, video, image or likeness in photographs and/or video for my child to be used at the discretion of Primrose Hill School for Newsletters, Flyers, Facebook, Website or news stories.
By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement.
Parent or Guardian *
Parent or Guardian
Today's Date *
Today's Date