Child Information

First Name *

Last Name *

Gender *

Male

Female

Other

Custody Info *

Yes

(If YES, you must provide legal document)

Date of birth *

Start Date *

PARENT/GUARDIAN 1

First Name *

last Name *

Relationship to child: *

Home Address *

City *

Postal Code *

Home Phone *

Cell Phone *

Work Phone *

Employer Name: *

Employer Address: *

Employer City: *

Employer Postal Code: *

Email Address *

(for school correspondence)

PARENT/GUARDIAN 2

First Name *

last Name *

Relationship to child: *

Home Address *

City *

Postal Code *

Home Phone *

Cell Phone *

Work Phone *

Employer Name: *

Employer Address: *

Employer City: *

Employer Postal Code: *

Email Address

(for school correspondence)

EMERGENCY CONTACT & AUTHORIZED PICK-UP (other than parent/guardian)

(1)Emergency Contact Name: *

Relationship to child *

Contact Tel: *

(2)Emergency Contact Name: *

Relationship to child: *

Contact Tel:

ADDITIONAL AUTHORIZED PICK-UP

Full Name of Person *

Relationship to Child

Full Name of Person *

Relationship to Child

Full Name of Person *

Relationship to Child *

ADDITIONAL AUTHORIZED PICK-UP

Full Name of Person *

Relationship to Child

Full Name of Person

Relationship to Child *

Full Name of Person *

Relationship to Child *

DOCTOR INFORMATION

Doctor Name *

Phone *

Doctor Address

MEDICAL INFORMATION

Has your child had Tuberculin?

Yes

(If yes, provide dateof test and results): *

Does your child take any medication(s) regularly?

Yes

(If yes, provide details, medication & dosage) *

ALLERGIES

a) Does your child have any KNOWN allergies at this time? *

Yes

*If yes, please check the following* *

Peanuts

Tree Nuts

Egg

Dairy

Insect Stings

Other

FOOD RESTRICTIONS (Non-Life-Threatening Restriction)

Vegetarian

Vegan

Halal

Kosher

No Pork

No Fish

No Egg

No Beef

Other

IMMUNIZATION RECORD

The student’s CURRENT immunization information is compulsory. A copy of the student’s immunization record is requested. If a copy of the immunization record is not available, please complete the table shown below.

Diphtheria

mm/dd.yyy

Tetanus

mm/dd.yyy

Pertussis

mm/dd.yyy

Polio

mm/dd.yyy

Hib

mm/dd.yyy

Pneumococcal

mm/dd.yyy

Rotavirus

mm/dd.yyy

Measles

mm/dd.yyy

Mumps

mm/dd.yyy

Rubella

mm/dd.yyy

Varicella

mm/dd.yyy

Meningococcal

mm/dd.yyy

Hepatitis B

mm/dd.yyy

HPV

mm/dd.yyy

Influenza

mm/dd.yyy

HepatitisA

mm/dd.yyy

Other

mm/dd.yyy

Yes, my child is fully immunized and a copy has been provided to the school

No, my child has not been immunized and a copy was provided of either:

Statement Of Religious Or Conscience Belief Form

Statement Of Medical Exemption Form

Statement Of Religious Or Conscience Belief Form

CREAMS/OINTMENTS AUTHORIZATION

All non-prescription creams/ointments must be given in the ORIGINAL container(includes but not limited to Vaseline, Penaten, Sudo Cream, etc.)

As the parent/guardian of the above child, I give permission for the staff of my child’s classroom to apply the following diaper cream(s):

Specify Brand:

To my child’s:

Diaper area

Others:

I would like this applied at

Every diaper change

When bum appears red

Others:

SUNSCREEN APPLICATIONAUTHORIZATION

Montessori School House does not accept sunblock with Arachidyl alcohol (peanut oil). Aveeno sunscreens other than Aveeno BABY brand have been known to include this ingredient therefore we are unable to accept them

I hereby give permission for the staff at Montessori School House to apply sunscreen when my child will be playing outside. I understand that sunscreen will be applied prior to going outdoors including, but not limited to the face (except eyelids, tops of ears, nose and exposed arms and legs.

Please apply sunscreen to my child

Please do not apply sunscreen to my child

If yes. Specify Brand.

Permission

the parent / guardian of

OUTINGS:give permission for my son/daughter to leave the premises to participate in any of our school events and places of interest as planned as part of the children’s program during the school year, including neighborhood nature walks. Parents will be notified of any field trips in advance.

PHOTOS:give permission for my child’s photograph to be used for school activities and school purposes only.

SLEEPING COTS:give permission for my child to use a sleeping cot if my child is 3.8 years of age or younger during rest time.

MEDICAL TREATMENT: authorize any doctor of a necessary treatment in the event of an emergency. MSH may be required to contact emergency help before attempting to reach parents. Parents will be immediately notified after emergency help is notified first. MSH and all staff members are hereby released from any liability due to circumstances and medical treatment received, as a result of such an emergency.

I have read and understood the terms above;

Parent/Guardian Signature *

Clear

Date

MEDIA RELEASE

I give Montessori School House permission to post photos and/or videos of my child on their private Instagram account(@MSHMaple). I understand these photos & videos will be used when creating the year-end school video. I understand that the school video can potentially be posted on the school’s website (www.montessorischoolhouse.ca)

I DO NOT give Montessori School House permission to post photos or videos of my child on the private Instagram account & school website. I understand that my child will not be featured in the year end school video

Parent/Guardian Signature *

Clear

Date

DAYS OF ATTENDANCE / PROGRAM SELECTION

CASA PROGRAM (3 year program includes, preschool, JK SK)

5 full days

Before care

5 half day

After Care

TODDLER PROGRAM

5 full days

5 half day

Infant PROGRAM

5 full days

5 half day

4 days

3 days

2 days

10 month program

12 month program

Parent/Guardian Signature *

Clear

Date

TERMS OF CONTRACT

All new applicants must pay a $250.00 registration fee which is non-refundable. This is a one-timefee

Security Fees are non-refundable

With all methods of payment, the last month’s fees are due at time of registration or re-enrollment(non-refundable)

All post-dated cheques must be dated for the first of each month and should include the child’s name on them

Written notice of a child’s withdrawal must be received 45 days prior to the intended date, otherwise 2 months tuition will be withheld.

There are no refunds/credits/make-up days for mid-month withdrawals, holidays, sick days,days missed or any other reason throughout the school year.

There are NO REFUNDS on lump sum payments.

There will be a $35.00 levied against all N.S.F. cheques or cheques returned for any reason. Where the appropriate replacement cheques or cash are not provided, Montessori School House reserves the right,which is not subject to challenge, in its sole and un fretted discretion to request the withdrawal of the child(ren).

The appropriate tax receipts will be remitted at the end of February.

There is a late pick up charge which is applied at the rate of $1.00/ minute after 6:00pm,or at any time that a teacher has to remain beyond established hours to care for a child due toa tardy parent/guardian

The enrollment policy is as follows:Parents/Guardians of children within the 5 full day program returning for another year have priority over all other programs offered, as well as new applicants until March 30th. If the administration fee(s) and post-dated cheques have not been received by this date, new applicants will be processed from our waiting list on a first-come-first-serve basis. You will forfeit any guarantee of placement

THIS REGISTRATION FORMIS CONTINUANCE OF EACH YEAR UNLESS A WRITTEN WITHDRAW NOTICE IS SUBMITTED TO THE OFFICE NO LATER THAN MAY 30th OF EACH YEAR

This is a legal and binding contract

Parent/Guardian Signature. *

Clear

Parent/Guardian Signature

Director Signature: *

Clear

Date

I agree that typing my name in the Parent/Guardian fields on this agreement is the legal equivalent to a handwritten signature

Registration form