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Emergency Information Form

This form is to be completed by the parent/guardian for each student attending MHC Academy.  Required fields marked are marked *. This form will be kept on file in the school office and in the nurse's office.

Attempts are ALWAYS made to contact a parent. In the event a parent cannot be reached, the relatives/friends designated below are authorized to pick up your daughter from school in case of emergency.

Please list only relatives or neighbors who are willing to pick up your daughter in case of illness or accident, or are willing to take responsibility for her in the rare instance of unscheduled early dismissals. 

Notify the school immediately if there are any court orders restricting non-custodial parents or others from contact with the child. Provide the Head of School with a copy of the order.

Physician's Information

Answer Required

Dentist's Information

Answer Required
I hereby authorize release of medical information to school personnel. In case of medical emergency, I hereby authorize the school to seek emergency medical assistance for our child if we cannot be reached.*
Answer Required
Confirmation Email