Director – Madhu Singh Admission and Registration Form Child`s

Date of Admission:
Director – Madhu Singh
Admission and Registration Form
Date of Withdrawal:
Child’s Name:__________________________ Date of Birth ______________________
Home Telephone No.______________________________________________________
Home Address: ___________________________________________________________
Class of Enrollment: _____________________________________________________________________
Hours/Days of Program Enrolled:
Days of Week: M T W Th F
After school
Other: ___________________________________
Parent/Guardian’s Name: ___________________________________________________
Mothers Phone No: Day: _____________________ Cell: _________________________
Fathers Phone No: Day: ______________________ Cell: ________________________
E-mail for correspondence: _________________________________________________
We will be using e-mail for correspondence regarding tuition/weekly updates/school closing, etc.
Parent/Guardian’s Home Address:
Same as Child’s
Other: ____________________________________________________________
Emergency Contact Information: Note: The listed person(s) must be willing to assist in the care/pick-up of your child in the
case that we are not able to contact you, please refer to handbook for details of emergency procedures.
Contact Name: ___________________________Relationship:____________________
Phone No:
1) _________________________ 2) _____________________________
Contact Name: ___________________________Relationship:____________________
Phone No:
1) _________________________ 2) _____________________________
Park Point Montessori is authorized to allow my child to leave the childcare facility ONLY with the
following person(s): (All persons are subject to a Photo ID/ DL check at front desk prior to pick-up of students)
Name: ________________________ Phone No.: _______________________________
Name: _________________________Phone No.: _______________________________
ALLERGIES: Include Food/Insects/Environmental/Medication allergies here.
1) __________________________ - Treatment needed: ____________________________________________
2) __________________________ - Treatment needed: ____________________________________________
3) __________________________ - Treatment needed: ____________________________________________
4) __________________________ - Treatment needed: ____________________________________________
Authorization for Emergency Medical Attention
Physician Name: _____________________________________ Phone No.: ____________________________
Address: __________________________________________________________________________________
Hospital Name: ______________________________________ Phone No.: ____________________________
Address: __________________________________________________________________________________
In the event of an accident/illness/emergency, I, the undersigned, do hereby authorize the Director/Staff representing Park Point Montessori School or an emergency vehicle to transport my
child to the nearest hospital and to render any and all necessary emergency treatments to my child. I, the undersigned, hereby authorize the Director/Staff representing Park Point Montessori
School to undertake any/all emergency measures to protect my child’s safety, while my child is in school. I fully understand that payment for all emergency medical treatment (medical,
hospital, ambulance/transport) is the sole responsibility of the Parent/Guardian. I will not hold the school, Director, and/or any Staff financially responsible for my child’s emergency care.
Signature – Parent or Legal Guardian
Admission and Registration Form (continued)
I DO give consent for my child to be transported and supervised by facility’s employees:
To and From Home
To and From School
On field trips
I DO NOT give consent for transportation (excluding emergency medical care/situations)
Water Activities :
I DO give consent for my child to participate in water activities including:
Splashing/Wading Pools
Water Table Play
Sprinkler Play
I DO NOT give consent for my child to participate in water activities.
Field Trips:
I DO give consent for my child to participate in Field Trips
I DO NOT give consent for my child to participate in Field Trips
I DO give my consent for my child’s picture to appear on the school’s website. (photos will not be sold or
circulated to any third parties).
List any special problems/ chronic illnesses / developmental disabilities below that may affect your child:
Has your child attended another pre-school? __________________________________________________
If Yes, Please give name and address for the other school.
Monthly/Weekly tuition fees includes all school holidays and will not be pro-rated if your child does not attend school due to sickness,
vacation, or other school/family holidays. All tuition for the month must be paid in full on or before the 5th day of the month or you will incur
late fees as per the Tuition Agreement. After the 15th day of the month, outstanding balances or unpaid tuition will keep your child from
attending school and you will be responsible for the balance of the tuition. Annual Registration and material fees are non-refundable and are
due with the enrollment form. A security deposit is also due at the time of enrollment and is refundable only if written notice is given to the
Director 30 days prior to withdrawal from the school. A new registration fee will be required to re-instate any returning students. Late fees
and returned check charges will be applied as per the Tuition Agreement.
All paperwork required for completion of enrollment to Park Point Montessori School (including Physician’s Forms, Immunization records,
and Emergency contact information) must be turned in within two weeks of student’s enrollment or your child may not attend school until
his/her file is complete.
I acknowledge receipt of the operational policies including those for discipline, guidance, and the financial agreement. I hereby agree to read,
follow, and abide by the school policies at all times.
Receipt of Written Operational Policies _______________________________________________
Signature of Parent/Guardian