CH Application Form

IvyCrest Montessori School Enrollment Application Form

Fullerton Campus
Have you toured IvyCrest Montessori?*
Preferred Date of Enrollment*

MonthDayYear
Date
Preferred Schedule*
Child's Information
Child's Legal Name

First NameMiddle NameLast Name
Home Address

Street Address

Street Address Line 2

CityState

ZIP
Home Phone Number or Primary Parent/Guardian's Main Phone Number*

Area CodePhone Number
Child's Gender*
Child's DOB (MM/DD/YY)*

MonthDayYear
Date
Child's Age (Years/Months)*
Child's Place of Birth (State/Country)*
Child's Primary Language*
Other Languages Spoken at Home*
Please "N/A" if needed.
Child lives with (Check all that apply):*

MOTHERFATHERGRANDPARENTSTEPMOTHERSTEPFATHERGUARDIANCAREGIVER
Primary Parent Information
Primary Parent/Guardian: Legal Name *
First, Middle, Last
Primary Parent/Guardian: Relationship to the Child*
(i.e. Mother, Father, etc.)
Primary Parent/Guardian: Driver License/ID Number*
In California, this number consists of 1 letter followed by 7 numbers.
Primary Parent/Guardian: E-mail Address*
example@example.com
Primary Parent/Guardian: Cell Phone Number*

Area CodePhone Number
Primary Parent/Guardian: Cell Phone Carrier*
i.e. T-Mobile, AT&T, etc. (This is needed for mass messaging purposes.)
Primary Parent/Guardian: Place of Birth (State/Country)*
Primary Parent/Guardian: Work Phone Number

Area CodePhone Number
Please enter your direct line extension (if any)
Primary Parent/Guardian: Home Address *
Street, City, State & ZIP
Primary Parent/Guardian: Occupation*
Please "N/A" if needed.
Primary Parent/Guardian: Employer*
Please "N/A" if needed.
Primary Parent/Guardian: Employer Address*
Please "N/A" if needed.
Does this child have a secondary parent/guardian?

YesNo
Secondary Parent's Information
Secondary Parent/Guardian: Legal Name*
First, Middle, Last
Secondary Parent/Guardian: Relationship to Child*
i.e. Mother, Father, etc.
Secondary Parent/Guardian: Driver's License/ ID Number*
In California, this number consists of a letter followed by 7 numbers.
Secondary Parent/Guardian: E-mail Address*
example@example.com
Secondary Parent/Guardian: Cell Phone Number*

Area CodePhone Number
Secondary Parent/Guardian: Cell Phone Carrier*
i.e. T-Mobile, AT&T, etc. (This is needed for mass messaging purposes)
Secondary Parent/Guardian: Work Phone Number and Extension (if applicable)

Area CodePhone Number
Please enter your direct line extension (if any)
Secondary Parent/Guardian: Place of Birth*
State/Country
Secondary Parent/Guardian: Home Address*
(Street, City, State, ZIP)
Secondary Parent/Guardian: Occupation*
Secondary Parent/Guardian: Employer*
Secondary Parent/Guardian: Employer Address*
Other Children in Family

From Oldest to Youngest
Are there other children in the family?*

YesNo
Additional Child #1: Legal Name*
Additional Child #1: Gender*
Additional Child #1: DOB*

MonthDayYear
Date
Additional Child #1: Name of School *
Please "N/A" if needed.
Additional Child #1: Grade Level*
Please "N/A" if needed.
Additional Child #1: Home Address (if different than IvyCrest Applicant)*
Please type "same" if the child lives in the same household as the IvyCrest applicant.
Add Another Child?*

YesNo
Additional Child #2: Legal Name*
Additional Child #2: DOB*

MonthDayYear
Date
Additional Child #2: Name of School*
Additional Child #2: Grade Level*
"N/A" if needed.
Additional Child #2: Gender*
Additional Child #2: Home Address (if different than IvyCrest applicant)*
Please type "same" if this child lives in the same household as the IvyCrest applicant.
Add Another Child?*

YesNo
Additional Child # 3: Legal Name*
Additional Child #3: Gender*
Additional Child #3: DOB*

MonthDayYear
Date
Additional Child # 3: Name of School*
Please "N/A if needed.
Additional Child #3: Grade Level*
Please "N/A" if needed.
Additional Child #3: Home Address (if different than IvyCrest applicant)*
Please type "same" if the child lives in the same household as the IvyCrest applicant.
Emergency Medical Treatment

Please read and sign below
I (WE) THE UNDERSIGNED, PARENTS OF Applicant's Legal Name*, A MINOR, DO HEREBY AUTHORIZE IVYCREST MONTESSORI PRIVATE SCHOOL, ITS ADULT AGENTS AND EMPLOYEES, TO CONSENT TO ANY EMERGENCY X-RAY, EXAMINATION, ANESTHETIC, MEDICAL, DENTAL, OR ANY EMERGENCY SURGICAL DIAGNOSIS OR TREATMENT AND HOSPITAL CARE TO BE RENDERED TO SAID MINOR. TREATMENT WILL BE ADMINISTERED UNDER THE GENERAL OR SPECIAL SUPERVISION AND UPON ADVICE OF A PHYSICIAN AND/OR SURGEON LICENSED UNDER THE PROVISIONS OF THE MEDICAL PRACTICE ACT OR DENTIST LICENSED UNDER THE PROVISIONS OF THE DENTAL PRACTICE ACT.

IT IS UNDERSTOOD THAT THIS AUTHORIZATION IS GIVEN IN ADVANCE OR ANY SPECIFIC EMERGENCY DIAGNOSIS, TREATMENT OR HOSPITAL CARE BEING REQUIRED, BUT IS GIVEN TO PROVIDE AUTHORITY AND POWER ON THE PART OF IVYCREST MONTESSORI PRIVATE SCHOOL, ITS ADULT AGENTS AND EMPLOYEES, TO GIVE SPECIFIC CONSENT TO ANY AND ALL SUCH EMERGENCY DIAGNOSIS, TREATMENT OR HOSPITAL CARE WHICH THE AFOREMENTIONED PHYSICIAN OR DENTIST IN THE EXERCISE OF HIS/HER BEST JUDGMENT MAY DEEM ADVISABLE.

IT IS UNDERSTOOD THAT I (WE), THE PARENT(S), WILL ASSUME FINANCIAL RESPONSIBILITY FOR COSTS INCURRED FOR TREATMENT AND/OR HOSPITAL CARE.

THIS AUTHORIZATION IS GIVEN PURSUANT TO THE PROVISION OF SECTION 25.8 OF THE CIVIL CODE OF CALIFORNIA.

THIS AUTHORIZATION SHALL REMAIN EFFECTIVE AS LONG AS MY CHILD IS ENROLLED IN IVYCREST MONTESSORI PRIVATE SCHOOL.
Primary Parent/Guardian Signature*
Today's Date*

MonthDayYear
Date
Name of Child's Physician*
Physician's Address*
Physician's Phone Number*

Area CodePhone Number
Today's Date*

MonthDayYear
Date
Name of Child's Dentist*
Dentist's Address*
Dentist's Phone Number*

Area CodePhone Number
Today's Date*

MonthDayYear
Date
Child's Medical Information
Does the applicant take any prescribed medication or need any special medical attention?*

YesNo
Please explain:*
Condition that requires child to take medication
Please "N/A" if needed.
Name of Medication
Please "N/A" if needed.
Does the child take any other medication?*

YesNo
Condition that requires child to take medication*
Name of Medication*
Please list any or all allergies the child has:*
Please "N/A" if needed.
Please list any and all dietary restrictions the child has:*
Please "N/A" if needed.
Please explain
Child's Student History
Child's Current School*
Please "N/A" if needed.
Child's Current School's Address*
Please "N/A" if needed.
Why are you thinking of leaving the child's current school?*
Please "N/A" if needed.
Has the child ever been evaluated for the following issues (if yes, please provide documentation):
Learning Differences*

YesNo
Psychological*

YesNo
Hearing*

YesNo
Behavior*

YesNo
Vision*

YesNo
I.Q. Testing*

YesNo
If you answered "yes" to any of the questions above, please provide supporting documentation either here or by turning in physical copies of results to the School Director.

Cancelof
Have there been any situations in the student's life that the school should know about in order to meet his/her learning or developmental needs? (i.e. frequent moves, changes in school, death in the family, divorce, etc.)*
"N/A" if not.
By court order, this child may not legally be released into the custody of (Please provide a copy of this court order for your files):*
"N/A" if needed.
If there is a person that the child applicant may not legally be released to, please provide supporting documentation either here or by giving physical copies of the court order, custody agreement or other related documents to the School Director.

Cancelof
DISCIPLINE POLICY

THE AIM OF THE MONTESSORI METHOD IS SELF-DISCIPLINE THROUGH PURPOSEFUL ACTIVITIES. THE IDEA IS TO LIKE WHAT YOU DO, BUT NOT DO AS YOU LIKE, THE RIGHTS AND SAFETY OF EACH PERSON MUST BE PRESERVED. CHILDREN ARE EXPECTED TO RESPECT THE AUTHORITY OF THE TEACHING STAFF, PARENT VOLUNTEERS, OTHER STUDENTS AND ALL PROPERTY, AT ALL TIMES. ANY STUDENT WHO IS UNWILLING TO ADHERE TO SCHOOL POLICIES WILL HAVE THEIR PARENTS CONTACTED TO DISCUSS POSITIVE STEPS FOR CORRECTION. IF DISRUPTIVE, VIOLENT BEHAVIOR OR REFUSAL TO OBEY AUTHORITY CONTINUES, THE FINAL STEP IS REMOVAL FROM THE PROGRAM.
Primary Parent/Guardian Legal Name*

First NameMiddle NameLast Name
Primary Parent/Guardian Signature*
Today's Date*

MonthDayYear
Date
OFF CAMPUS POLICY

IVYCREST MONTESSORI ADOPTS THE CA EDUCATION CODE 35330, STATING THAT ALL CHILDREN OR THEIR PARENTS PARTICIPATING IN A SCHOOL-RELATED TRIP OR ACTIVITY WAIVE ALL CLAIMS AGAINST THE SCHOOL FOR INJURY, ACCIDENT, ILLNESS, OR DEATH OCCURING BY REASON OF THE ACTIVITY OR TRANSPORATION.
I, THE PARENT/GUARDIAN OF APPLICANT'S LEGAL NAME*, GIVE MY PERMISSION TO IVYCREST MONTESSORI AND THE TRANSPORTATION PROVIDER TO TRANSPORT OUR CHILDREN FOR ANY OFF CAMPUS ACTIVITIES. WE UNDERSTAND THE LIABILITY ASPECTS AS SPECIFIED IN CA EDUCATION CODE SECTION 35330.
Primary Parent/Guardian Legal Name*

First NameMiddle NameLast Name
Primary Parent/Guardian Signature*
Today's Date*

MonthDayYear
Date
I (WE) HEREBY AGREE WITH AND VERIFY, TO THE BEST OF MY (OUR) KNOWLEDGE, THAT ALL THE INFORMATION ON THESE FORMS ARE TRUE AND CORRECT.
Primary Parent/Guardian Legal Name*

First NameMiddle NameLast Name
Primary Parent/Guardian Signature*
Today's Date*

MonthDayYear
Date
Secondary Parent/Guardian Legal Name

First NameMiddle NameLast Name
Secondary Parent/Guardian Signature
Today's Date

MonthDayYear
Date

IvyCrest Montessori School Enrollment Application Form

Child's Information

Primary Parent Information

Secondary Parent's Information

Other Children in Family

Emergency Medical Treatment

Child's Medical Information

Child's Student History