Marketplace Mission Learning Center Forms

Marketplace Mission Learning Center

STUDENT ENROLLMENT FORM

2017-2018


Student Name
First:___________________________________ MI _______ Last ____________________________________

Address: __________________________________________________________________________________

City: _________________________________ State: _______________________ Zip: ____________________

Student                                 Student
Home/Cell Phone: (       )_______________________ Email: _________________________________________

Birth: _______ Mo. _______ Day _______Yr.              Number of Sisters:_______  Number of Brothers:________

Student Likes To Be Called:______________________________________

Today’s Date: __________________________________  Grade:______________________________________

Emergency Contact Name:____________________________ Phone:__________________________________

Contact’s Relation to Student: __________________________________________________________________

Doctor: __________________________________ Phone:_______________ Hospital Preference: ___________


PARENT/GUARDIAN INFORMATION

Father’s Name:_____________________________  Mother’s Name:___________________________________

Marital Status: _____________________________  Marital Status: ____________________________________

Address:__________________________________  Address: _________________________________________

City/State/Zip: _____________________________  City/State/Zip: _____________________________________

Employer: ________________________________  Employer: ________________________________________

Occupation: ______________________________   Occupation: _______________________________________

Phone:___________________________________  Phone: ___________________________________________

Email: ___________________________________  Email: ____________________________________________


Payment Plan: Pay For 10 Months @$ __________________ per month  

                       Pay For Full Year   @$___________________

Parents Signatures: ___________________________________________________________________________
 

 

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Marketplace Mission Learning Center

Emergency Medical Authorization Form 

2017-2018

Name: Student ____________________________________________________________________________
Birth Date: ________________________       Grade: _____________________________________________
Street Address: ____________________________________________________________________________
City: ________________________________________________ State:_______________________________ Zip:___________________

Purpose – To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while under school authority, when parents or guardians cannot be reached.

Parent/Guardian Information:

Mother’s Name ___________________________________________________________________________
                                                                           
Daytime Phone:________________________________    Cell Phone:________________________________
                                                                                                                              
Father’s Name ____________________________________________________________________________
                                                                        
Daytime Phone:________________________________  Cell Phone:_________________________________
 
                                                                                                                                   
Guardian’s Name: _________________________________________________________________________
                                                                               
Daytime Phone:__________________________________ Cell Phone:_______________________________
                                                                                                                                    
Name of Relative or Childcare Provider:
________________________________________________________________________________________

Relationship: _________________________________________________________________________________________

Daytime Phone:______________________________  Cell Phone:____________________________________

Street Address: _____________________________________________________________________________
City: ________________________________________________ State:_______________________ Zip:________________________

PART 1 OR 2 MUST BE COMPLETED

PART 1: TO GRANT CONSENT - I hereby give consent for the following medical care provider and local hospital to be called:

Physician: _______________________________________________________________________________
Phone Number:__________________________________________________

Dentist: ________________________________________________________________________________
Phone Number:__________________________________________________


Medical Specialist: _______________________________________________________________________
Phone Number:__________________________________________________

Local Hospital: __________________________________________________________________________
Phone Number:__________________________________________________

In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by above named doctors or in the event the designated preferred practitioner is not available by another licensed physician or dentist, and (2) the transfer of my child to any hospital reasonably accessible.
               This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.

               Facts concerning my child’s medical history, including allergies, medications being taken and any physical impairments to which a physician should be alerted:
________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________

Date: ________________
Parent/Guardian Signature:___________________________________________________________
Street Address: ____________________________________________________________________
City: ________________________________________________ State:________________________ Zip:_______________________




PART 2: REFUSAL TO CONSENT – I DO NOT give my consent for emergency medical treatment of my child.  In the even of illness or injury requiring emergency treatment, I wish the school to take the following action:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________

Date: ___________________  
Parent/Guardian Signature:________________________________________________________
Street Address: ____________________________________________________________________
City: ________________________________________________ State:_______________________ Zip:__________________________

 

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Marketplace Mission Learning Center

2017-2018 STUDENT FIELD TRIP PERMISSION FORM


I hereby give permission for my child(ren) to attend all field trips and excursions of Marketplace Mission Learning Center (MMLC) during the school year. I understand that  MMLC will arrange transportation which includes travel by privately owned vehicles. I release and discharge Marketplace Mission Learning Center from any and all liability including but not limited to any liability arising out of the operation of any privately owned vehicles in connection with accidents or injuries which occur on such trips regardless of cause.

If your student takes personal belongings such as watches, purses, money, cameras, and wallets, etc.on any field trip, MMLC accepts no responsibility for them. If a student stores personal items in a locker at a site, for example, that entity may be responsible for any loss or damage. There may be a minimal charge for field trips to cover expenses.

This permission form remains in effect unless and until I notify, in writing, the head of Marketplace Mission Learning Center to the contrary.

          
Student(s) Name


___________________________________________________________________________


___________________________________________________________________________


___________________________________________________________________________






___________________________________________________________________________
Signature of Parent or Guardian                            Date

 

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