Infant-Toddler Application - Growing Minds Montessori School

Select Program

Frequency

Student's Full Name Name

First Middle Last

Name Used / Nickname

Gender

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Date of Birth

Age in August

Present School / Daycare

Number of Years in System

Start Date

Is another child in your family applying?

Yes
No

Mother's Info

Mother's Name*

First Last

Mother's Email*

Mother's Phone

Mother's Occupation

Mother's Business Phone

Father's Info

Father's Name

First Last

Father's Email

Father's Phone

Father's Occupation

Father's Business Phone

Physician Info

Physician's Name

First Last

Physician's Phone

Physician's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

May the school call another physician if unable to contact the above?

Yes
No

Emergency Contact Info

Other person to be notified in case of illness or accident:

Name

First Last

Relationship

Phone

People permitted to pick up the child

Mother

Yes
No

Father

Yes
No

Other people permitted to pick up the child:

Name

First Last

Relationship

Phone

Name

First Last

Relationship

Phone

Additional Info

Does your child have any difficulties with:

Eyes
Ears
Speech

Are there any conditions in the family that might affect the adjustment of the child?

Name and ages of siblings or other members in the family:

Special instructions or areas of concern:

This form must accompany a registration fee of $250.00 to reserve a spot for your child. The registration fee is non-refundable, and non-transferable. *All applications are based off of a first come, first serve basis, and therefore submitting an application does not guarantee admission.

Parent's Name

First Last

Parent's Signature

Date

Comments

This field is for validation purposes and should be left unchanged.