Student Information Sheet - Miss Marsha`s Mini School

Miss Marsha’s Mini School
596 Oldham Avenue
Henderson, NV 89014
702-458-4566
STUDENT INFORMATION SHEET
CHILD’S NAME
BIRTH DATE
MY CHILD GOES BY THE NAME
ADDRESS
CITY
ZIP
PHONE
CELL PHONE
GENDER
FATHER’S NAME
OCCUPATION
EMPLOYER
MOTHER’S NAME
EMPLOYER
WORK PHONE
OCCUPATION
WORK PHONE
In case of emergency:
DOCTOR
PHONE
FOOD OR DRUG ALLERGIES
Name of persons to notify in an emergency or who may pick up your child:
NAME
PHONE
NAME
PHONE
AUTOMOBILE USED TO PICK UP CHILD:
MODEL
MAKE
COLOR
LICENSE PLATE #
Names and ages of other children living in your household:
I,
hereby give my consent for employees of Miss Marsha’s Mini School, LLC to call
a physician and authorize medical or surgical care of my child,
should an emergency arise
where such service is indicated. It is understood that a conscientious effort must be made to notify me before such action
is taken. If it is impossible to locate me or my spouse, the expense of this service will be accepted by me.
Further, I agree to hold Josephine Falcone and her agents or employees safe and harmless for or from any liability,
damage, injury or harm of whatever nature which may arise from any cause or source except the express negligence of
Miss Marsha’s Mini School, LLC.
Signature of parent/guardian
Date