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TODDLER
Primary - Ages 3-6
Elementary - Ages 6-9
Elementary - Ages 9-12
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PROCESS
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>
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Summer Program
SCHEDULE A TOUR
ABOUT US
Mission & Philosophy
Our Directors
School Calendar
ACADEMICS
TODDLER
Primary - Ages 3-6
Elementary - Ages 6-9
Elementary - Ages 9-12
Enrichment Classes
ADMISSIONS
PROCESS
Tuition
FORMS
>
Emergency Care
Enrollment Forms
>
Enrollment Form
Re-enrollment Form
Apply Now
Summer Program
SCHEDULE A TOUR
2021-2022 Enrollment Form
STUDENT INFORMATION
Student Information:
*
Indicates required field
STUDENT NAME
*
First
Last
Gender
*
Male
Female
Age
*
BIRTH DATE
*
mm/dd/yyyy
ADDRESS
*
Line 1
Line 2
City
State
Zip Code
Country
HOME PHONE
*
Languages Spoken at Home
*
Any Allergies?
*
Yes
No
You will be asked for more detailed information later in the application.
Program Seeking to Enroll in 2021-2022
*
Toddler (15 months - 3 years)
Primary (3 - 6 years)
Elementary
Schedule
*
8:00 AM - 12:00 PM (Toddler ages 1-3)
8:00 AM - 2:00 PM (Toddler ages 1-3)
8:00 AM - 5:30 PM (Toddler ages 1-3)
8:15 AM - 12:15 PM (Primary ages 3-5)
8:15 AM - 2:15 PM (Primary ages 3-5)
8:15 AM - 5:30 PM (Primary ages 3-5)
8:30 AM - 3:00 PM (Elementary ages 6-12)
8:30 AM - 5:300 PM (Elementary ages 6-12)
PARENT INFORMATION:
Father's Name
*
First
Last
Profession
*
Address (if different from above)
*
Line 1
Line 2
City
State
Zip Code
Country
Email
*
Cell Phone Number
*
Mother's Name
*
First
Last
Profession
*
Address (if different from above)
*
Line 1
Line 2
City
State
Zip Code
Country
Email
*
Cell Phone Number
*
Authorized Pick-up Persons/ Emergency Contact
Please list any persons authorized to pickup your child. The additional checkbox can be checked off if the person is also an emergency contact.
At least one authorized pick-up is required.
Authorized Pickup Person 1
*
First
Last
Relationship
*
Phone Number
*
Emergency Contact
*
Yes, This person is also an emergency contact
check this box If you would like this authorize this person as an emergency contact
Authorized Pickup Person 2
*
First
Last
Relationship
*
Phone Number
*
Emergency Contact 2
*
Yes, This person is also an emergency contact
Authorized Pickup Person 3
*
First
Last
Relationship
*
Phone Number
*
Emergency Contact 3
*
Yes, This person is also an emergency contact
Authorized Pickup Person 4
*
First
Last
Relationship
*
Phone Number
*
Emergency Contact 4
*
Yes, This person is also an emergency contact
Health Information:
Current Health Conditions (Please detail any health conditions and requirements we should be aware of)
*
Are there any regular medication your child is taking? *
*
Allergies:
*
Food
Medicine
Bee or Insect Stings
None
Please list any specific allergies or sensitivities
*
Emergency Care Authorization
*
I authorize Medina Montessori to take the appropriate measures to provide emergency care for my child. This may include calling emergency care personel.
Physician Name
*
Does your child have health insurance?
*
Yes
No
Physicians Phone Number
*
Insurance Phone Number
*
First aid and emergency treatment will be provided to students in accordance with the student's individualized health plan.
Financial Agreement
Payment Authorization
*
I authorize Medina Montessori to charge my $200 annual materials fee once this form is received as well as monthly tuition on the 1st of each month. I understand that any change in billing or cancellation requires 30 notice.
Payment Method
*
Will provide new payment info
Use account on file
Medina Montessori does not discriminate on the basis of religion, gender, race, national, or ethnic origin in the administration of its educational policies, admissions policies, scholarship and loan programs, and other school-administrated programs.
Submit Enrollment Form
