2017-2018 Medical Information and Permission Form




Student 1 Information

(if different from First Name)​​​​

Student 1 Health Information

Student 2 Information

(if different from First Name)​​​​​​​

Student 2 Medical Information

Student 3 Information

(if different from First Name)​​​​​​

Student 3 Medical Information

Student 4 Information

(if different from First Name)​​​​​​​​

Student 4 Medical Information

Medical Insurance

All students must be covered by medical and accident insurance. The Montgomery Academy does not provide medical or accident coverage for students.

I grant permission for the following physician or dentist, or other members of the physician's or dentist's practice, to treat my child in the event that my spouse or I cannot be reached:

Emergency Contact Information

In the event of an emergency where neither I nor my spouse can be reached, please contact:

If applicable, the following individuals have permission to pick my child//children up from school:

Field Trip/Off Campus Activity Permission, Waiver, and Release

My child has my permission to attend and participate in any field trip and/or school-sponsored off-campus activity (hereinafter, collectively referred to as “off-campus activity”) in which The Montgomery Academy is participating during the 2017-2018 school year. I understand that such off-campus activity will involve traveling off campus and may involve traveling to locations outside the City of Montgomery, Alabama or the State of Alabama. I further understand that when traveling to an off-campus activity, my child may ride in a vehicle driven by an administrator, agent, volunteer, or employee of The Montgomery Academy.

For and in consideration of my child’s participation in any such off-campus activity, I hereby release and discharge The Montgomery Academy, its trustees, board of trustees, administrators, agents, volunteers, employees, and independent contractors from any and all liability, claims, demands, losses, or damages in connection with any injuries or damages sustained by my child in connection with any off-campus activity during the above-referenced school year, including, but not limited to, travel to and from the off-campus activity and all actions undertaken during, and incidental to, the off-campus activity.

I have fully read this agreement and fully understand its terms and conditions. I understand that my child and I have given up substantial rights by signing this agreement and I have signed it freely without any inducement or assurance of any nature, and intend it to be a complete and unconditional release of any and all liability to the greatest extent allowed by law. I agree that if any portion of this agreement is held to be invalid that the remainder, notwithstanding, shall continue in full force and effect.

I give my consent for The Montgomery Academy's employees, nurses, and coaches to use their best judgment in securing medical aid and/or ambulance service in the event of a medical/dental emergency.

I hereby release The Montgomery Academy, its directors, officers, employees, and agents from any and all liability, of any nature and character, which may be alleged to arise out of or relating to the assistance described above.