Summer Data Collection Process

Please complete this survey no later than August 1. We suggest that you use a laptop or larger screen device, rather than your phone, to complete this survey. Questions marked with an asterisk must be answered in order to submit the survey at the end.


If you are logged into the Montgomery website portal, some of the fields in the survey will prefill with the information we currently have in the website directory database. If any information is incorrect, just click on that box, and type in the correct information. Pertinent medical information will be provided to faculty and staff.


When you are finished, please click submit to register your information. You may save this questionnaire if it is not complete, and return to complete it at a later time. Contact Janis Oeschger or Stacey Kley with any questions.


Parent Contact Information

Parent #1:

Parent's cell and home phone numbers will be included in the online and printed directory, and will be included in our Emergency Notification System, unless you contact Janis Oeschger and provide her with different instructions by August 1.

​​
Please provide your home phone if you have one.​
Please provide your work phone if you have one.​
This must be the email you use for school communications, and website log in.​​​ Each parent must have their own unique email address to log into the website.​
Provide name of your business, or enter "none" if applicable.​​​​​​​
Provide your title, or enter "none" if applicable.​​​​​​​
Position or Title​​​
Please list any corporate board, non-profit board, or foundation experience.​​
What school district does your child(ren) reside in?​​​​​​

Health Insurance Information

Please provide the subscriber name for the policy that your child is a part of.​

You will be asked to provide a policy number for each child within the student section.


In the event of an emergency or early dismissal if the parent or guardian cannot be reached, we will call your emergency contacts. Please provide information below for 2 emergency contacts for your child(ren).

Emergency Contact #1

First and last name.​​​​​
Additional phone for this emergency contact.​​​​
Please note your child's relationship to this emergency contact.​​​​​

Emergency Contact #2

First and last name.​​
Additional phone for this emergency contact.​​
Please note your child's relationship to this emergency contact.​​​​

Parent #2/Spouse/Partner: If both parents reside in the same home, please answer yes below, and complete all of the information for this parent #2/spouse/partner. Parents who live in a different home will be responsible for completing this information via their own survey.​

Do both parents reside in the same home?​​​​
Please provide your work phone number if you have one.​
This must be the email you use for school communications, and website log in.​​​​ Each parent must have their own unique email to log into the website.​​​
Provide name of your business, or enter "none" if applicable.​​​​​​​
Provide your title, or enter "none" if applicable.​​
Position or Title​​​
Please list any corporate board, non-profit board or foundation experience.​​​

Student Information

Student #1

Please check all that apply.​​​​​
Grade this child will enter in 2016-2017 school year.​​

The dismissal questions below will establish your child's normal method of dismissal each day of the week. If you need to make a change to dismissal for a particular day, you will be able to use the dismissal change form anytime prior to 1:30 pm to inform the school of a change This dismissal change form can be found on quicklinks during the school year.

Please select your child's dismissal for Mondays.​​​
Please select your child's dismissal for Tuesdays.​​​​
Please select your child's dismissal for Wednesdays.​​
Please select your child's dismissal for Thursdays.​​
Please select your child's dismissal for Fridays.​
Please check the box below if you give permission for the school nurse to administer age-appropriate doses of the following (brand or generic) to your child.​​​​
Please indicate your preferred hospital for your child.​​​​​​​
Does your child have any known ALLERGIC reaction to BEE/INSECT STINGS, DRUG, FOOD, or OTHER SUBSTANCE?​​​​
If YES to any of the above, explain any past reactions to Allergen and Treatment.​​​ For the safety of your child, this information will be shared with faculty and staff.​​​​​
Is your child taking any daily prescription or over the counter medications?​ For the safety of your child, it is imperative that you disclose any and all medications that your child is taking. If you wish to discuss any concerns with the school nurse, please contact Robin Chronowski (rchronowski@montgomeryschool.org).​​​
If you answered yes to the question above, please explain what medications and why.​​ ​​​
Please list any conditions that require special attention (ie. Asthma, ADD, ADHD, Migraines, Heart, Seizures, Diabetes, etc.)​​
My child wears the following. Please check all that apply.​​
Please note other device that your child wears/uses.​
Has your child been hospitalized during the past year.​​
If your child has been hospitalized during the past year, please explain the reasons below.​​​
Are there any court mandated custody/visitation orders limiting access to this student?​ ​​​​
Please attach a copy of any court mandated custody or visitation orders here, or provide to Janis Oeschger by August 1.​​​
Max file size: 10 MB
Do you have a second child who will attend Montgomery School in the 2016-2017 school year?​​​​​

Student #2

Please select all that apply.​​​​
Grade this child will enter in 2016-2017 school year.​​​​
Please select your child's dismissal for Mondays.​​
Please select your child's dismissal for Tuesdays.​​
Please select your child's dismissal for Wednesdays.​
Please select your child's dismissal for Thursdays.​
Please select your child's dismissal for Fridays.​
Please check the box below if you give permission for the school nurse to administer age-appropriate doses of the following (brand or generic) to your child.​​​​​​
Please indicate your preferred hospital for your child.​​​​​​​​​
Does your child have any known ALLERGIC reaction to BEE/INSECT STINGS, DRUG, FOOD, or OTHER SUBSTANCE?​​​​
If YES to any of the above, explain Allergen, Reaction and Treatment.​​​
Is your child taking any daily prescription or over the counter medications?​​​​​
If you answered yes to the question above, please explain what medications and why.​​​​​
Please list any conditions that require special attention (ie. Asthma, ADD, ADHD, Migraines, Heart, Seizures, Diabetes, etc.)​​​​
My child wears the following. Please check all that apply.​​​​
Please note other device that your child wears/uses.​
Has your child been hospitalized during the past year.​​​​
If your child has been hospitalized during the past year, please explain the reasons below.​​​
Are there any court mandated custody/visitation orders limiting access to this student? ​​​​​
Please attach a copy of any court mandated custody or visitation orders here, or provide to Janis Oeschger by August 1.​​​​
Max file size: 10 MB
Do you have a third child who will attend Montgomery School in the 2016-2017 school year?​​​​​​​​​​​​​

Student #3

Please select all that apply.​​​
Grade this child will enter in 2016-2017 school year.​​
Please select your child's dismissal for Mondays.​
Please select your child's dismissal for Tuesdays.​
Please select your child's dismissal for Wednesdays.​
Please select your child's dismissal for Thursdays.​
Please select your child's dismissal for Fridays.​
Please check the box below if you give permission for the school nurse to administer age-appropriate doses of the following (brand or generic) to your child.​​​
Please indicate your preferred hospital for your child.​​​​​​
Does your child have any known ALLERGIC reaction to BEE/INSECT STINGS, DRUG, FOOD, or OTHER SUBSTANCE?​​​​
If YES to any of the above, explain Allergen, Reaction and Treatment.​​​
Is your child taking any daily prescription or over the counter medications?​​
If you answered yes to the question above, please explain what medications and why.​​​​
Please list any conditions that require special attention (ie. Asthma, ADD, ADHD, Migraines, Heart, Seizures, Diabetes, etc.)​​
My child wears the following. Please check all that apply.​​
Please note other device that your child wears/uses.​​​
Has your child been hospitalized during the past year.​​
If your child has been hospitalized during the past year, please explain the reasons below.​​​​​
Are there any court mandated custody/visitation orders limiting access to this student? ​​​
Please attach a copy of any court mandated custody or visitation orders here, or provide to Janis Oeschger by August 1.​​​​
Max file size: 10 MB
Do you have a fourth child who will attend Montgomery School in 2016-2017?​​​​​​​

Student #4

Please select all that apply.​​​
Grade this child will enter in 2016-2017 school year.​​
Please select your child's dismissal for Mondays.​
Please select your child's dismissal for Tuesdays.​
Please select your child's dismissal for Wednesdays.​
Please select your child's dismissal for Thursdays.​
Please select your child's dismissal for Fridays.​
Please check the box below if you give permission for the school nurse to administer age-appropriate doses of the following (brand or generic) to your child.​​
Please indicate your preferred hospital for your child.​​​​​​​
Does your child have any known ALLERGIC reaction to BEE/INSECT STINGS, DRUG, FOOD, or OTHER SUBSTANCE?​​​
If YES to any of the above, explain Allergen, Reaction and Treatment.​​​
Is your child taking any daily prescription or over the counter medications?​
If you answered yes to the question above, please explain what medications and why.​​​
Please list any conditions that require special attention (ie. Asthma, ADD, ADHD, Migraines, Heart, Seizures, Diabetes, etc.)​
My child wears the following. Please check all that apply.​
Please note other device that your child wears/uses.​​
Has your child been hospitalized during the past year.​
If your child has been hospitalized during the past year, please explain the reasons below.​​
Are there any court mandated custody/visitation orders limiting access to this student?​​​
Please attach a copy of any court mandated custody or visitation orders here, or provide to Janis Oeschger by August 1.​​​
Max file size: 10 MB

Grandparent and Special Friend Information

Please provide contact information below for your child(ren)'s grandparents or special friends. Each spring we host GrandFriends Day, a wonderful morning for grandparents and special friends to visit Montgomery School. The school will send invitations to those people whom you designate below.

GrandFriend #1

Please select the relationship of this person to your child.​​​​
Please provide "other" information.​​​
Do you have another grandparent or special friend to add?​​​​​​

GrandFriend #2

Please select the relationship of this person to your child.​​
Please provide "other" information.​
Do you have another grandparent or special friend to add?​​

GrandFriend #3

Please select the relationship of this person to your child.​​
Please provide "other" information.​

If you have any additional grandparents or special friends, please contact Allison Stinger, Director of Development, and provide her with this same contact information for any additional GrandFriends Day guests.

I understand, acknowledge and agree to the following:

  • Non-prescription medication must be accompanied by a note from the parent/guardian in the original labeled package. Prescription medications may be administered in the Health Room with a Request for Administration of Medication Formsigned by the health care provider and parent/guardian. The medication must be in the original container and prescribed for the child to whom it is to be given. The label must include the child's name, physician's name, drug name, dose, directions for administration, and date of prescription. THE INITIAL DOSE MAY NOT BE GIVEN AT SCHOOL. Students may not carry medications at school unless for emergency purposes. Students may carry emergency medication on their person if a written physician's order is on file in the Health Room.
  • That the School staff are not trained or licenses health care professionals (except the School Nurse); that due to daily School schedules, medication may not be administered precisely when due; that if lack of regularity with the administration of the medication is a problem, the school will be notified, and that I (we) will provide a list of any necessary precautions which should accompany the medication and/or any side effects that I (we) wish the School to watch for and notify me (us) if they occur.
  • In consideration for the above, and intending to be legally bound, I (we), on my (our) behalf and on behalf of the student, hearby release the School, and its staff and agents, from any and all liability arising directly and indirectly out of, or in connection with, the handling and administration of medication to the student.
  • This student also has my permission to engage in all School sponsored activities including, but not limited to, field trips and sporting events.
  • All the information provided is accurate. It is my (our) responsibility to advise the School of any change in any of the above information. I (we) agree that this release is intended to be as broad and inclusive in protecting the School, its staff and agents as is permitted by the law of Pennsylvania and that if any portion herof is held invalid, the balance shall continue in full legal force and effect.

Textbook Loan Form
State Law (Act 195) authorizes the loan of textbooks by the Secretary of Edcuation to children enrolled in nonpublic schools. Act 90 authorizes the loan of instructional materials. Our school is now in the process of requesting the specific textbooks and materials to be loaned by your children. The law requires that a parent/guardian of each child attending the non-public school individually request a loan of textbooks and instructional materials. By signing below, you are requesting the loan of textbooks and instructional materials in accordance with Pennsylvania Act 195 and Act 90 for your child(ren) attending Montgomery School.

Materials Release
By signing below, you grant permission to Montgomery School to use images, videos, writings, art, and/or recording of your children in our printed materials, on our website, and in other electronic means of communication. These materials will not be used for any non-school related purpose. Your permission relates to Montgomery School official or endorsed materials only. Your signature below provides permission to use, in whole or in part, images, videos, writing, art, and/or audio recordings of your child(ren) for the purpose of internal and external publications, in both printed and electronic form. For more information, please contact Stacey Kley, Director of External Affairs.

I affirm that entering my cell phone number and name below, and submitting this form constitutes an electronic signature of this form.​​​​​​​
Please enter your name below to acknowledge that the information above is correct, and that you are in agreement with the above statements.​

Please provide an email address where we can send a link to your current form.

Email Address :