Durham Montessori School and Daycare
Registration Form
e: info @dmsd.ca / 200 Byron St S, Whitby, ON, L1N 4 P6 / p: 905-665-0505
Student Information
Name
*
First Name
Middle Name
Last Name
Birth Date
*
-
Month
-
Day
Year
Start Date
*
-
Month
-
Day
Year
MM-DD-YYYY
Have you been referred to Durham Montessori School and Daycare or has a family previously attended our school?
*
Yes
No
If yes, please explain.
Are you expecting?
*
Yes
No
Parent/Guardian 1
Name
*
First Name
Last Name
Relationship to Child
*
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Contact Number
*
Employeer
*
Profession
*
Work Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Work Number
*
Please enter a valid phone number.
Parent/Guardian 2
Name
*
First Name
Last Name
Relationship to Child
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Contact Number
*
Please enter a valid phone number.
Employeer
*
Profession
*
Work Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Work Number
*
Please enter a valid phone number.
Parent/Guardian Residence Information (if different from above)
Name
First Name
Last Name
Relationship to Child
Email
example@example.com
Address
Street Address
Street Address Line 2
City
Province
Postal Code
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Emergency Contact 1
Name
*
First Name
Last Name
Contact Number
*
-
Area Code
Phone Number
Relationship to Child
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Emergency Contact 2
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Relationship to Child
*
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Authorization for Pickup
Your child will only be released to an authorized person listed on this form (parent/guardian and/or emergency contact if notified by parent/guardian via phone or email). In case of an emergency or an unforeseen circumstance, please indicate the name, address and phone number of any other person/s who you authorize to pick up your child on your behalf.
Name 1:
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Phone Number
*
Please enter a valid phone number.
Name 2:
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Phone Number
*
Please enter a valid phone number.
Name 3:
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Phone Number
*
Please enter a valid phone number.
A parent/guardian's verbal or written authorization for pickup must be received by Durham Montessori School and Daycare Staff before your child will be released including to anyone listed here. If not received, and we cannot notify you by phone, the child will not be released. Please note that the person picking up must provide Photo Identification, Contact Information and be 18 years or older before child can be released.
Physician and Medical Information
Name
*
Prefix
First Name
Last Name
Office Phone:
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Health Card #
Allergies
Medical Information
(Please list food, seasonal allergies, etc)
Medications
Does your child have any dietary restrictions?
*
(vegetarian/vegan/egg/fish/dairy, etc)
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Immunization
The Child Care and Early Years Act requires that we have a photocopy of your child's recent immunization record in our files. Please include a photocopy with this registration form. If you do not have the records, a copy can be obtained from your Doctor.
File Upload
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of
Communicable Diseases
(Check those that your child has had):
*
COVID-19
CHICKEN POX
MEASLES
GERMAN MEASLES
PNEUMONIA
RHEUMATIC FEVER
WHOOPING COUGH
FIFTH DISEASE
FREQUENT COLDS
BRONCHITI
MIDDLE EAR INFECTION
TONSILITIS
SCARLET FEVER
NONE
Drop Off And Pick-Up Times
Morning Drop Off
Please Select
7:00 A.M - 7:15 A.M
7:15 A.M - 7:30 A.M
7:30 A.M - 7:45 A.M
7:45 A.M - 8:00 A.M
8:00 A.M - 8:15 A.M
8:15 A.M - 8:30 A.M
8:30 A.M - 8:45 A.M
8:45 A.M - 9:00 A.M
9:00 A.M - 9:15 A.M
9:15 A.M - 9:30 A.M
Afternoon Pick Up
Please Select
3:00 P.M - 3:15 P.M
3:15 P.M - 3:30 P.M
3:30 P.M - 3:45 P.M
3:45 P.M - 4:00 P.M
4:00 P.M - 4:15 P.M
4:15 P.M - 4:30 P.M
4:30 P.M - 4:45 P.M
4:45 P.M - 5:00 P.M
We expect full participation from your child in all aspects of the program to the best of their ability. This includes involvement in program-based activities, both indoor and outdoor gross motor activities, as well as rest time. If your child is unable to participate due to illness, we kindly require that you keep them at home for 24 hours symptom free before returning to program. I acknowledge and agree with the above statement, and I commit to keeping my child at home when they are unwell. I understand that I must arrange for their pickup within one hour if they become ill during the day. Furthermore, parents are required to provide one month's written notice if they wish to change the number of childcare days and is subject to availability. It is important to note that if my child is picked up during the day for any reason including appointments, they are not permitted to return to the program for the remainder of that day.
Signature of Parent/Guardian:
*
Date
*
-
Month
-
Day
Year
Signature of Director/Supervisor:
Date:
Parent Consent Form
Child's Name:
*
First Name
Last Name
FIELD TRIPS/VISITORS
I hereby give consent for my child to participate in excursions, within walking distance of the school, under the guidance of the staff of Durham Montessori School and Daycare.
*
My Child may participate in the above field trips
My Child may not participate in the above field trips
I understand monthly visitors/trips are apart of the program. If I do not wish for my child to participate, I will still be required to pay for the program fees for that day and will not bring my child to school until 12pm, or when normal programming resumes for that day should programming resume later than 12pm.
Signature of Parent/Guardian:
*
Medical Attention
In the event of an emergency, I understand and agree that my son/daughter, will receive:
*
Whatever first aid is available
Whatever additional medical assistance is required and available
Such other emergency assistance as may be required to safeguard life and/or prevent injury
I understand further that I will be informed of the situation as soon as possible and that initial contact will be attempted by calling the telephone number(s) noted in the registration form.
*
I give consent for my child to be transported by transportation arranged by Durham Montessori School and Daycare (ambulance, staff, taxi, etc) as required
I do not give consent for my child to be transported by transportation arranged by Durham Montessori School and Daycare (ambulance, staff, taxi, etc) as required
Signature of Parent/Guardian:
*
Date
*
-
Month
-
Day
Year
Date
Videotape/Photo Consent Form
From time to time, staff will videotape or photograph the children at Durham Montessori School and Daycare. Both the photos and videos are useful for staff training, community and education awareness purposes. Occasionally, they may appear in the newspapers, our website, Facebook and/or Instagram. Please select ONE of the following choices.
*
I give consent for Durham Montessori School and Daycare staff to use video/photos of my child(ren) for classroom and school use only.
I give consent for Durham Montessori School and Daycare staff to use video/photos of my child(ren) for uses inside and outside the school.
I do not give consent for video/photographs to be taken of my child in any capacity including, HiMama or other school communication apps.
Signature of Parent/Guardian:
*
Date
*
-
Month
-
Day
Year
Date
Background Information
Child's Name:
*
First Name
Last Name
1. Brothers or Sisters:
*
2. Favourite friend, relative or babysitter, real or imaginary:
*
3. It is important that my child learns:
*
4. Favourite place to go:
*
5. Family Activities:
*
6. What the child does when upset, how can we comfort them? :
*
7. Toilet Trained (Yes/No)
*
including naptime
8. Any other services involved with the child?
*
including speech therapist, Grandview kids, etc
EMERGENCY CLASSROOM RECORD
Name of Child:
*
First Name
Last Name
Health Card Number:
Date of Birth:
*
-
Month
-
Day
Year
Date
Parent/Guardian 1
*
First Name
Last Name
Home Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Contact Number
*
Please enter a valid phone number.
Work Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Work Number
*
Please enter a valid phone number.
Parent/Guardian 2 Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Contact Number
*
Please enter a valid phone number.
Work Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Work Number
*
Please enter a valid phone number.
Doctor's Name
*
Doctor's Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Doctor's Phone Number
*
Please enter a valid phone number.
Emergency Contacts (If different from above)
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
Province
Postal Code
Contact Number
Please enter a valid phone number.
Name 2
First Name
Last Name
Address
Street Address
Street Address Line 2
City
Province
Postal Code
Contact Number
Please enter a valid phone number.
Additional Information (Allergies, Special Medical Requirements, etc):
Symptoms of Ill Health:
Please inform the office of any other vital information you think they may need to know in the event of an emergency. Thank you.
PROGRAM DAILY FEES
Monthly tuition fees are payable to Durham Montessori School and Daycare before the 1st of every month. If the 1st falls on a weekend, holiday, or school closure, the childcare payment is required by the Friday before. There is a late fee charge of $5.00 per day effective on the 1st day of every month. If the fees are not submitted by the 2nd day of the month, a letter will be issued which states childcare services will be terminated immediately. Childcare fees are subject to increase and policies may change before the child's start date. Durham Montessori School and Care will be accepting payments by E-Transfer, cash, money order, certified cheque, and preauthorized payments. If a parent is late to pick up their child at the school's closing time, a late pick-up fee of $2 per minute applies. An invoice will be sent, and an E-Transfer is to be made within 24 hours. Our program fee will not change while child is registered at Durham Montessori School and Daycare until the following September regardless of age or classroom change.
REGISTRATION FEE: $500.00 (per child)
DEPOSIT FEE: $500.00 (per child)
Parents are required to provide two (2) months written notice of withdrawal during business hours. Failure to provide adequate notice will result in the forfeiture of the deposit paid at the time of registration. Deposits will only be applied to the last month's childcare invoice. Your child's spot is reserved for 1 year from the start date, otherwise, the deposit fee will not be refunded unless amended by the director at registration. The deposit is NON-REFUNDABLE even if parents decide to withdraw their child before the agreed start date on the registration form or the first month with Durham Montessori School and Dare. Parents are required to pay daily program fees for all Statutory Holidays, Winter Break, March Break, Summer Break, and sudden interruption of classroom or other school closures.
I have read and understand Durham Montessori School and Daycare's payment requirements and agree to accept all the school's policies and any additional information or policies added annually in Durham Montessori School and Daycare's Parent Handbook made available to me to print on their website (www.dmsd.ca).
Signature of Parent/Guardian:
*
Date:
*
-
Month
-
Day
Year
Date
Signature of Director/Supervisor:
Date:
Blanket Form For All Products Administered By Durham Montessori School and Daycare Staff
Durham Montessori School and Daycare staff are hereby authorized to administer sunscreen, diaper rash cream, insect repellent, lip balm, body moisturizers and/or other products supplied by their parents/guardians daily or whenever needed.
Child's Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Signature of Parent/Guardian
*
Our Programs
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*ADMIN USE ONLY*
Room Registered:
Full-Time/Part-Time Registered:
Start Date:
End Date:
Registration Received:
Deposit Received:
Deposit Returned:
Immunization Received:
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