Child's Information

Last Name:

First Name:

Home Street Address:

City:

Prov.:

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Postal Code:

Home Phone Number:

Child’s First Language:

What language(s) is/are spoken at home?

Child’s Date of Birth:

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Child’s Gender:

MaleFemale

Admission Requested For:

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Parent/Guardian Information

Parent/Guardian Completing the Application Form: Mr.Mrs.Ms.Dr.

Last Name:

First Name:

Relationship to Child:

Occupation/Title

Email Address:

Work Phone Number:

Cell/Home Phone Number:

Other Parent/Guardian: Mr.Mrs.Ms.Dr.

Last Name:

First Name:

Relationship to Child:

Occupation/Title

Email Address:

Work Phone Number:

Cell/Home Phone Number:

Parental Status: Single
Married
Common Law
Separated
Divorced
Other, please explain:

Sibling Information

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

Name:

Age:

Financial Responsibility of the Student’s Tuition Will Be Assumed By:

Last Name:

First Name:

Relationship to Child:

Phone Number:

Other Information about Your Child:

Does Your Child Currently Attend A Preschool Or Daycare?

YesNo

Preschool/Daycare Name:

Phone Number:

Preschool/Daycare Director or Owner’s Name:

Is your child potty trained?

YesIn ProgressNo

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

YesNo

If yes, please describe:

Are there any medical or emotional concerns that we should be aware of?

YesNo

If yes, please describe:

Are your child’s immunizations up to date?

YesNo

Are there any dietary restrictions that your child must follow?

YesNo

If yes, please describe:

Does your child have any allergies or physical limitations?

YesNo

If yes, please describe:

Is your child on medication?

YesNo

If yes, please describe:

Has your child ever suffered any serious illness, injury or hospitalization?

YesNo

If yes, please describe:

Has your child had any specialized evaluations or received any counseling or therapy?

YesNo

If yes, please describe:

Does your child have any special needs?

YesNo

If yes, please describe:

Has your child’s present preschool/daycare/dayhome made any special accommodations for your child?

YesNo

If yes, please describe:

Final Details:

What are you hoping to find in a preschool for your child?

What would you most like to see Montessori & Me accomplish with your child over the next three/four years?

How does your child spend his/her time outside of school (e.g. sports, programs, interests, etc.)?

Do you share our commitment to having your child attend Montessori & Me in their Kindergarten year?

YesNo

Preferred Program Time

AMPM

How did you learn about our school?

Website
Friend
Family
Other, please explain

A non-refundable Application Fee of $75.00 must be received by mail before this application will be considered as a formal request for enrollment of your son or daughter at Montessori & Me.

All information provided is considered highly confidential and only the Program Director will have access to it.

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