Pre-Registration Form

Pre-Registration Form
Today's Date*

MonthDayYear
Date
1. Child's Full Name*

First NameLast Name
Nickname
(if applicable)
Age
ie: 6 months or 5 years
Date of Birth

MonthDayYear
If you are expecting a child, please enter your anticipated due date.
Sex*
Child's Current School
If you have a second child you wish to enroll, please select "Yes" to fill out their information below.*

Yes - I have a second child I wish to enrollNo - I only have one child I wish to enroll
2. Second Child's Full Name

First NameLast Name
Second Child's Nickname
Second Child's Age
example: 6 months or 5 years
Second Child's Date of Birth

MonthDayYear
Date
Second Child's Sex
Second Child's Current School
Names & Ages of Siblings
Child's Home Phone*
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Is your Home Address the same as your Mailing Address?*

YesNo
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Parent / Guardian Information
Mother / Guardian #1 Full Name*

First NameLast Name
Mother / Guardian #1 Cell Phone*
Mother / Guardian #1 Work Phone
Mother / Guardian #1 Email*
example@example.com
Mother / Guardian #1 Employer*
Mother / Guardian #1 Employer Address*
Mother / Guardian #1 Occupation*
Days at Work per Week*
example: If you work Monday - Friday, type "5"
Hours at Work per Day*
example: If you work 9-5, type "8"
Father / Guardian #2 Full Name*

First NameLast Name
Father / Guardian #2 Cell Phone*
Father / Guardian #2 Work Phone
Father / Guardian #2 Email*
example@example.com
Father / Guardian #2 Employer*
Father / Guardian #2 Employer's Address*
Father / Guardian #2 Occupation*
Days at Work per Week*
example: If you work Monday through Friday, type "5".
Hours at Work per Day*
example: If you work 9-5, type "8"
Preferred Schedule & Start Days
Desired Start Date*

MonthDayYear
Date
Preferred Schedule*
Please select one*

Although the schedule indicated above is preferred, please contact me about any schedule that becomes available.Please only contact me about the schedule indicated above.
Who should be contacted when an opening becomes available?*

Mother / Guardian #1Father / Guardian #2
If you wish for us to use a different email address to contact you than the email provided by the selected guardian, please enter below:
example@example.com
How did you hear about Patience Montessori School? Please check all that apply.

ParentNewspaper / AdvertisementFacebook / Social MediaInternet SearchYellow PagesOther
Additional Information (If Applicable)
Parent / Guardian with Legal Custody

First NameLast Name
Parents are:
Decree on File?

YesNo
*By signing below, you agree that this is a legally binding form. Providing false information will result in termination of childcare services, and forfeiture of retainer.
Mother / Guardian #1 Signature*

Clear
Father / Guardian #2 Signature*

Clear
Date of Signatures*

MonthDayYear
Date
Total Invoice Cost

Pre-Registration Form

Parent / Guardian Information

Preferred Schedule & Start Days

Additional Information (If Applicable)