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

AUTHORIZED PICK-UP

Full Name of Person

Relationship to Child

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

Please provide date of test and results):

Does your child take any medication(s) regularly? *

Yes

Please 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)

a) Does your child have any food/dietary restrictions? *

Yes

Please select all that apply:

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): *

Yes

Specify Brand:

To my child’s:

Diaper area

Others:

I would like this applied at

Every diaper change

When bum appears red

Others:

SUNSCREEN APPLICATION AUTHORIZATION

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 select one of the following options:

Apply provided sunscreen to my child ( I give permission to apply sunscreen to my child using the sunscreen that I provide. I confirm that the sunscreen is safe for my child to use)

Do not apply sunscreen to my child (I do not wish for sunscreen to be applied to my child. I understand that my child will not receive any sunscreen protection during outdoor activities)

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

DAYS OF ATTENDANCE / PROGRAM SELECTION

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

5 full days

Before care

After Care

TODDLER PROGRAM

5 full days

Infant PROGRAM

5 full days

10 month program

12 month program

Parent/Guardian Signature *

Clear

Date

TERMS OF CONTRACT

I have read, understood, and agree to all terms and conditions outlined in this contract with Montessori School House

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

Parent/Guardian Signature *

Clear

Date

Director Signature (for internal use):

Clear

Date

Registration form

Registration for enrollment is now closed.

Please check back at a later time when registration re-opens.

Thank you.