Media and Medical Release Forms

At MLC, the safety and protection of our students is our top priority. The policies provided here—including our Media and Medical Release forms—help us maintain clear communication with families and ensure that each child’s individual needs are respected. These guidelines allow us to create a secure and supportive environment for learning and growth.

Below you will find MLC's Media Release Policy and the Emergency Information/Medical Release Form.

Emergency Information and Medical Release Form

This form provides essential medical and emergency contact information to be used in the event of an illness, accident, or other urgent situation involving a student. All information will remain confidential and will be used solely for the purpose of protecting the health and safety of the student.

Student Emergency Information and Medical Release Form

Student Full Name*

Date of Birth*

Grade*

Home Address*

City, State, and Zip Code*

Parent/Guardian #1 Full Name*

Relationship to Student (Parent/Guardian #1)*

Cell Phone Number (Parent/Guardian #1)*

Work Phone Number (Parent/Guardian #1)

Home Phone Number (Parent/Guardian #1)

Email (Parent/Guardian #1)*

Parent/Guardian #2 Full Name*

Relationship to Student (Parent/Guardian #2)*

Cell Phone Number (Parent/Guardian #2)*

Work Phone Number (Parent/Guardian #2)

Home Phone Number (Parent/Guardian #2)

Email (Parent/Guardian #2)*

Emergency Contact #1 Full Name (Other than Parents)*

Emergency Contact #1 Relationship to Student*

Emergency Contact #1 Cell Phone Number *

Emergency Contact #1 Email *

Emergency Contact #2 Full Name (Other than Parents)*

Emergency Contact #2 Relationship to Student *

Emergency Contact #2 Cell Phone Number*

Emergency Contact #2 Email

Primary Care Physician Full Name*

Primacy Care Physician's Phone Number*

Preferred Hospital*

Insurance Provider*

Does the student have any allergies? If yes, please list and describe reactions.*

Does the student have any medical conditions? If yes, please describe.*

Is the student currently taking any medications? If yes, please list medications and dosages.*

Additional Information: Please use the space below to share any additional information that may be helpful or necessary for school staff or emergency personnel to know. If not applicable, disregard this section.

By entering my name below, I certify that I am the parent or legal guardian of the student and I authorize school personnel to seek and obtain necessary emergency medical treatment for my child in the event that I cannot be reached in an emergency.*

Media and Medical Release Forms

Media Release Policy

Emergency Information and Medical Release Form

Montessori Learning Center

Contact Info

Newsletter/Inquiry