Student Application Form

* First Name:

Middle Name:

* Last Name:

* Birthday (mm/dd/yyyy):

* Address:

* City:

* Province:

* Postal Code:

Parent/Guardian 1

Parent/Guardian 2

Name

Telephone

( )

( )

Business

( )

( )

Cell

( )

( )

Fax

( )

( )

Occupation

* Email

Parental Status:
Married Single Divorced Separated Remarried

Child Resides with:
Both Parents
Parent/Guardian 1
Parent/Guardian 2
Grandparents
Other (Please specify):

Contact Name:

Contact Phone:
( )

Family Physician:

Physician Phone:
( )

Are your child's immunizations up-to-date?
Yes No Unsure

Known Alllergies:

Is your child on medication? If yes, please detail:

Please list the names and ages of sibilings in your home:

Does your child have any special needs? If yes, please detail:

Is your child frightened of anything we should be aware of?

Does your child still nap? If so, at what time:
No
Yes (Time:)

When was your child potty trained (age in months)?

Are there any dietary restrictions your child must follow? If yes, describe in detail:

Do you share our commitment to the three-year Montessori Program:
Yes No Unsure

How did you learn about our school?
Website
Print Ad
From a Friend
Other (Please Specify):

Preferred program time:
AM PM Either

Projected entry date: