Texas Dept of Family
ADMISSION INFORMATION
and Protective Services
Page 2 of 2
HEALTH REQUIREMENTS
Name of Child:
Date of Birth:
Prefered Hospital:
Insurance Provider:
Policy Number:
For governmental reporting purposes, please indicate the ethnicity you prefer for your child:
€ Asian € Black/African American
€ Hispanic/Latino
€ Inter-Racial
€ Native American
€ Pacific-Islander
€ White/Caucasian
Name of Dentist:
Address:
Phone:
List any physical limitations your child may have, such as speech, hearing, etc.:
List any medical conditions, such as asthma, allergies, etc.:
Has your child ever exhibited any emotional problems? If so, please explain:
Does your child take medication on a regular basis? If so, please list the medication by name and dosage:
Has your child had surgery? If so, please list the procedure and date:
The above information is complete and correct. If there are any changes during the school year, I understand that it is my responsibility to notify Montessori
Children’s House. I understand that I will be notified at once in case of accident or illness to my child, and I will make arrangements for medical care of my
child with the physician or hospital of my choice. If I cannot be reached to make necessary arrangements, or in a critical emergency requiring medical care, I
hereby authorize Montessori Children’s House to contact the above named physician or dentist for treatment.
Signature – Parent or Legal Guardian
Date