Child’s Name: ________________________             _____________________________________

                                       (first name)                                                             (last name)

 

Date of Birth: __________________________            Male/Female: __________________________

                                       (mm/dd/yyyy)

 

Home Address: _________________________           City: ____________ Postal Code: __________

 

Home Telephone: _______________________            Language(s) spoken at home: ______________

 

 

Mother’s Name: _______________________         ______________________________

                                                           (first name)                                                                                 (last name)

 

Employer Name: ________________________          Occupation: _____________________

 

Business Phone: _________________________         Cell Phone: ______________________

 

(If different From Child’s Address)

 

Home Address: _________________________                    City: ___________ Postal Code: ______

 

Home Phone: ___________________________

 

 

Father’s Name: _______________________           _____________________________

                                                      (first name)                                                                                     (last name)

 

Employer Name: ________________________          Occupation: ___________________

 

Business Phone: ________________________           Cell Phone: ______________________

 

(If different From Child’s Address)

 

Home Address: _________________________                    City: ___________ Postal Code: ______

 

Home Telephone: ________________________

 

 

  O  Primary (Casa): 2 ½ - 3 ½  years old  (Morning Half day)      

 

  O  Primary (Casa): 3 ½ - 6 years old  (Full day)

 

  O  Elementary: 6 - 9 years old (Full day)

 

  O  Elementary: 9 - 12 years old (Full day)

 

 

  O  Before-School Program  (7:30 a.m. – 8:45 a.m.)                   O  After-School Program  (3:30 p.m. – 6:00 p.m.)

 

 

  O  Bus Transportation  

 

                        O Home pick-up                    (7:00 a.m. – 9:00 a.m.)

                        O Home drop-off                   (11:45 a.m. – 1:00 p.m.)

                        O Home drop-off                   (3:30 p.m. – 5:00 p.m.)

                        O Home drop-off                   (4:15 p.m. – 6:00 p.m.)

 

 

  O  Lunch Program (Available to full day Casa students only)

 

        List Allergies and/or Religious Dietary Restrictions:

 

                        __________________________________________________________________

 

                        __________________________________________________________________

                       

 

Person(s) to be contacted in case of emergency where parent(s) cannot be reached.

 

                        Emergency Contact Person (1)                         Emergency Contact Person (2)

Contact (1) Name: ________________________       Contact (2) Name: _____________________

Relationship to child: _______________________      Relationship to child: ____________________

Contact (1) Home Phone: ___________________      Contact (2) Home Phone: ________________

Contact (1) Work Phone: ___________________      Contact (2) Work Phone: ________________

Contact (1) Cell Phone: _____________________     Contact (2) Cell Phone: __________________

 

 

Student’s Health Card Number:  ____________________________________

 

List any food and/or other allergies/religious dietary restrictions.  Please describe any allergic reactions (i.e. rash, swelling, convulsions, etc.).

 

____________________________________________________________________________

 

____________________________________________________________________________

 

 

Please list any pertinent health needs or conditions of your child such as lengthy illness, vision/hearing problems or regular medication including name of drug, reason and dosage details.

 

____________________________________________________________________________

 

____________________________________________________________________________

 

 

Child’s Doctor Information                                                   Child’s Dentist Information

 

Name: ___________________________                               Name: ________________________

 

Address: _________________________                    Address: ______________________

 

Phone Number: ____________________                   Phone Number: _________________

 

 

I, the Parent/Guardian of ___________________________________ hereby give authorization for the following person(s) to pick up my child from Humberside Montessori School in my absence.

 

 

               Name                        Relationship                 Home Phone               Work Phone

 

1. __________________   __________________    ________________   ________________

 

2. __________________   __________________   ________________   _________________

 

3. __________________   __________________   ________________   _________________

 

 

 

 

I, ___________________________, the parent of ___________________________________, understand that in the event of an accident or illness occurring to my child, the School will make every attempt to contact me and/or my spouse.  If however, I or my spouse cannot be reached, I hereby give Humberside Montessori School, its Directors, Officers, Agents and Employees authority to act on my behalf in case of an emergency and to take appropriate steps to have my child’s physician or other physician or paramedic attend to my child.

 

 

I, _________________________________, the parent of ____________________________ hereby grant permission for my child to use all of the play equipment and participate in all of the activities of the school, and to take part in any out-of-school events under the supervision of a staff member for neighbourhood walks or field trips in an authorized vehicle.  In addition, “Going Out” is an important part of the Elementary Montessori program involving small groups of children who plan and execute excursions into the neighbouring community.  Walking or utilizing public transportation if necessary and accompanied* by a staff-appointed chaperon, “Going Out” experiences allow children to participate and explore our social and cultural society in relationship to school-related projects and activities.

(*Consultation with parents of children in the Elementary 9-12 level will determine if their child may leave school premises un-chaperoned.)

 

 

Please comment on the level of development that your child demonstrates in the following areas:

 

Independence (e.g. physical ability to manipulate clothing, desire to care for himself/herself, ability to verbalize needs, etc.):

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

Socialization (e.g. ability to understand and obey limits, and control behavioural impulses, responsibility and helpfulness around the home and with younger siblings etc.):

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

Initiative (demonstrates ability to initiate activities independently versus a need to be entertained, etc.):

 

______________________________________________________________________________

 

______________________________________________________________________________

 

______________________________________________________________________________

 

 

 

List name and address of any previous school or daycare most recently attended by your child and/or if your child had a nanny:

 

______________________________________________________________________________

 

Why have you chosen Montessori Education for your child?

 

______________________________________________________________________________

 

______________________________________________________________________________

 

How did you learn of Humberside Montessori School?  ____________________________________

 

List in order of importance, reasons that most influenced your decision to enrol your child with Humberside Montessori School.

 

1. _________________________________________          Other: _________________________

 

2. _________________________________________                     ________________________

 

3. _________________________________________                      ________________________

 

1.         A child will be considered accepted into the school when a completed and signed enrolment for as well as all post dated-cheques for the full year and the deposit in advance of the last month’s fees have been submitted.

 

2.         All new applicants must pay a $200.00 registration fee that is non-refundable.

 

3.         The last month’s deposit is non-refundable after April 1^st.

 

4.         There are no refunds or deduction in fees for days the school is closed, holidays, sick days or mid-month withdrawals throughout the school year.

 

5.         Written notice of student’s withdrawal must be received one month in advance of intended date of withdrawal.  Post-dated cheques will be returned, and unused pre-paid tuition will be refunded less pro-rated time of attendance based on the regular monthly fee.