Martin Montessori Academy Enrollment Form

Child Enrollment Form

(Enrollment not official until form 100% completed AND $75 registration fee received. $25 to hold spot for one week, $50 per week thereafter, WITH Director's approval)

How did you hear about us?

Please fill out ALL FIELDS

Other source information

Child's Legal Name

Date Enrolled

MonthDayYear

Preferred name/nickname

Boy or Girl?

Birth Date

MonthDayYear

Address

City

Zip

Best Number

Who has legal custody?

Put your name(s) here

Relationship to Child

Address (just put a "1" in field if same as primary address)

City (put a "1" in field if same as primary city)

Zip (put a "1" in field if same as primary zip)

Phone Number (put a "1" in field if same as primary phone)

Child lives with?

Put your name(s) here

Mother's Name

First NameLast Name

Cell Number

Mother's Cell Phone Carrier

(for emergency communications)

Home Phone (put a "1" if no home phone number)

Address (put a "1" or a "2" if it's the same as either of the first two addresses)

City (put a "1" or a "2" if it's the same as either of the first two)

Zip (put a "1" or a "2" if it's the same as either of the first two)

Mother's Employer

Work Phone

Work Address

City

Zip

Father's Name

First NameLast Name

Cell Number

Father's Cell Phone Carrier

(for emergency communications)

Home Phone (put a "1" if no home phone number)

Address (put a "1" or a "2" if it's the same as either of the first two addresses)

City (put a "1" or a "2" if same)

Zip (put a "1" or a "2" if same)

Father's Employer

Work Phone

Work Address

City

Zip

Is your child related to the provider?

If so, how is your child related to the provider?

Person 1 permitted to remove child

First NameLast Name

Address

City

Zip

Best Number

Relationship to Child of Person 1 with permission to remove?

Person 2 permitted to remove child

First NameLast Name

Address

City

Zip

Best Number

Relationship to Child of Person 2 with permission to remove?

Person 1 to be notified of an emergency [other than parents] (put a "3" if same as person 1 with permission to remove, "4" if same as person two)

First NameLast Name

Address

City

Zip

Home Phone

Cell Number

Person 2 to be notified of an emergency [other than parents] (put a "3" if same as person 1 with permission to remove, "4" if same as person two)

First NameLast Name

Address

City

Zip

Home Phone

Cell Number

Child's Physician/Health Care Resource

Physician's Phone #

Physician's Address

Physician's City

Physician's Zip

Child's Dentist (If no Dentist yet, put a "5" in this field)

Dentist's Phone # (If no Dentist yet, put a "5" in this field)

Dentist's Address (If no Dentist yet, put a "5" in this field)

Dentist's City (If no Dentist yet, put a "5" in this field)

Dentist's Zip (If no Dentist yet, put a "5" in this field)

Communicable Diseases

Medicines Routinely Taken

Earaches?

Diabetes?

Allergies

Skin problems?

Eating problems?

Vomitting/diarrhea?

Frequent Throat colds?

Other chronic conditions?

Physical or mental disabilities?

Identifying marks

Special needs of child

Toileting

Fears

Additional info

Hours that your child will be attending

Meals typically attending

Mother's Birthday (just day and month is fine)

MonthDayYear

Mom's Email

Father's Birthday (just day and month is fine)

MonthDayYear

Dad's Email

Hospital Preference

Hospital City

Medical Insurance Company

Policy Number

Expiration Date