Child Registration Form

MOUNTAIN LAUREL MONTESSORI SCHOOL CHILD REGISTRATION FORM
To save partial and continue later, scroll to the bottom and click "Save and Continue Later." You will recieve an email with a link to continue.
Child*

First NameMiddle NameLast Name
Nickname
Date of Birth*

MonthDayYear
Date
Gender*
Program*
Toddler, Primary, Elementary, Middle School
Grade
Age*
PARENT(S)/GUARDIAN(S)
Parent/Guardian 1*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone *
If you do not have a home phone, please enter cell phone number.
Cell Phone*
Please enter a valid phone number.
Place of Employment *
Please note if unemployed or retired.
Business Phone*
If you do not have a home phone, please enter cell phone number.
Email*
example@example.com
Email
example@example.com
Photo of Parent/Guardian 1*

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Parent/Guardian 2*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone *
If you do not have a home phone, please enter cell phone number.
Cell Phone*
Please enter a valid phone number.
Place of Employment *
Please note if unemployed or retired.
Business Phone*
If you do not have a home phone, please enter cell phone number.
Email*
example@example.com
Email
example@example.com
Photo of Parent/Guardian 2*

Cancelof
Additional notes regarding contacting parent/guardian in case of emergency
MEDICAL INFORMATION
Chronic physical problems/pertinent developmental information/special accommodations*

YesNo
If yes, please explain *
Does your child have allergies or intolerance to food, medication, etc.?*

YesNo
If yes, please list and explain action plan *
Child's Physician*
Phone*
HOLD HARMLESS AND INDEMNITY AGREEMENT
The undersigned, on behalf of themselves, their spouses (as the case may be), their representatives, heirs, successors and assigns hereby (1) authorizes the persons identified below to transport and remove the child/children identified above to and from the premises of Mountain Laurel Montessori School from time to time, and (2) agrees to indemnify and hold harmless Mountain Laurel Montessori School, its employees, agents, contractors and students, from and against any and all actions, causes of actions, costs, damages, claims, and liabilities of any nature whatsoever arising from or related to the transport and removal of the child/children identified above by the individuals identified below or which may otherwise occur while the child/children is/are in the care, custody, and control of the Individuals Identified below.

Effective: November 1, 2020, in the Commonwealth of Virginia

List two people to contact if parent(s)/guardian(s) cannot be reached.

Contacts may not be a parent/guardian listed above and must be located within a 30 mile radius of the school.
1. Name of Emergency Contact *

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Photo of Emergency Contact 1*

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2. Name of Emergency Contact *

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Photo of Emergency Contact 2*

Cancelof
List all other adults who may also pick up your child.
1.

First NameLast Name
1. Photo Upload*

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2.

First NameLast Name
2. Photo Upload*

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3.

First NameLast Name
3. Photo Upload*

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4.

First NameLast Name
4. Photo Upload*

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5.

First NameLast Name
5. Photo Upload*

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6.

First NameLast Name
6. Photo Upload*

Cancelof
7.

First NameLast Name
7. Photo Upload*

Cancelof
8.

First NameLast Name
8. Photo Upload*

Cancelof
9.

First NameLast Name
9. Photo Upload*

Cancelof
10.

First NameLast Name
10. Photo Upload*

Cancelof
11.

First NameLast Name
11. Photo Upload*

Cancelof
12.

First NameLast Name
12. Photo Upload*

Cancelof
The above information is true and correct for the 2025-2026 school year, including 2025 Summer Camp and 2025 Bumper Weeks, if attending. Signature*

Clear
Date*

MonthDayYear
Date
UPDATED (PLEASE ENTER THE DATE AND TIME)*

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

MOUNTAIN LAUREL MONTESSORI SCHOOL CHILD REGISTRATION FORM

PARENT(S)/GUARDIAN(S)

MEDICAL INFORMATION

HOLD HARMLESS AND INDEMNITY AGREEMENT

List all other adults who may also pick up your child.