stcroixmontessori.files.wordpress.com file · web viewdoes your child have any medical conditions...

ENROLLMENT APPLICATION2017-2018 School Year

Please include a non-refundable application fee of $20.00.

Child’s Name: _____________________________________________________________________________________Last First M.I

Birth Date: ________________________ Age_____ Sex___M___F mo/day/yr

Previous Schooling (List names of schools previously attended, and the age of the child while attending) _________________________________

____________________________________________________________________________________________________________

PARENT/GUARDIAN INFORMATION

Parent A/Guardian Name:Mr./Mrs./Ms./Dr.____________________________________________________________________________________

Physical Address___________________________________________________________________________________________

Mailing Address____________________________________________________________________________________________

Telephone: Home________________________ Cell___________________ E-Mail_____________________________

Place of Employment___________________________________________ Position___________________________________

Business Address________________________________________________ Telephone_________________________

Parent B/Guardian Name:Mr./Mrs./Ms./Dr.____________________________________________________________________________________

Physical Address___________________________________________________________________________________________

Mailing Address____________________________________________________________________________________________

Revised March 2017 | of 6

3013 Orange GroveChristiansted, VI 00820

P: [email protected]

www.stcroixmontessori.com

Telephone: Home________________________ Cell___________________ E-Mail_____________________________

Place of Employment___________________________________________ Position___________________________________

Business Address________________________________________________ Telephone_________________________

Child Lives With _____Both Parents ______Parent A ______Parent B EMERGENCY CONTACT / AUTHORIZED CONTACT / PICK UP (OTHER THAN PARENTS)

Contact #1: ________________________________________ Relationship____________________________

Primary Phone #_____________________________________ Secondary Phone #______________________


Primary Phone #__________________________________ Secondary Phone #_____________________


Primary Phone #_____________________________________ Secondary Phone #____________________


Primary Phone #__________________________________ Secondary Phone #______________________

EMERGENCY MEDICAL INFORMATION

Pediatrician_____________________________________________ Phone ________________________

Dentist ________________________________________________ Phone________________________

Medical Conditions: Asthma___ Diabetes___ Epilepsy___ Heart Condition___

Other (Please Describe) ____________________________________________________________________________

Allergies: Bee Sting___ Nuts____ Peanuts____ Other_____________________________________

Does your child have any medical conditions that may inhibit physical activity? Y N





If

yes, please Explain:

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Medication (indicate dosage and reason for taking) _________________________________________________________

__________________________________________________________________________________________

Medicine will not be administered (prescription or non-prescription) without note from doctor and medicine in labeled packaging.





PERMISSION TO SWIM

Can your child swim? Y N How far can your child swim? _____________________________________________

Check the appropriate box below.

I give my child permission to go in the water at the beach and/or pool.

I do not give my child permission to go in the water at the beach and/or pool.

____________________________________________________________ ____________________________________ Parent’s Signature Date





FIELD TRIP AND ACCIDENT RELEASE

I give my child permission to participate in all school activities (except if otherwise indicated on this

form) and school sponsored trips away from the school premises throughout the current school year. I

understand that I may revoke my permission for specific field trips by notifying the school prior to the

outing. I understand there are risks involved in participating in off campus trips. I agree to defend,

indemnify, and hold harmless Montessori House of Children, Inc. d/b/a St. Croix Montessori School, its

employees, agents, and representatives including volunteers and drivers, from any and all claims

arising from my child’s participation in such trips. In the case of an accident, illness, or other

emergency, I give the school permission to call paramedics and/or licensed physicians or dentists. I

assume the financial responsibility for expenses incurred as the result of those services.

I do not give my child permission to participate in all school activities (except if otherwise indicated on

this form) and school sponsored trips away from the school premises throughout the current school

year. I understand that I may revoke my permission for specific field trips by notifying the school prior

to the outing. I understand there are risks involved in participating in off campus trips. I agree to

defend, indemnify, and hold harmless Montessori House of Children, Inc. d/b/a St. Croix Montessori

School, its employees, agents, and representatives including volunteers and drivers, from any and all

claims arising from my child’s participation in such trips. In the case of an accident, illness, or other

emergency, I give the school permission to call paramedics and/or licensed physicians or dentists. I

assume the financial responsibility for expenses incurred as the result of those services.

BOTH PARENTS AND OR GAURDIANS MUST SIGN OR YOUR CHILD WILL NOT BE PERMITTED TO ATTEND TRIPS.

Parent (A) Signature: Date:

Parent (A) Print Name:

Parent (B) Signature:Date:

Parent (B) Print Name:





PHOTOGRAPHY/VIDEO/MEDIA RELEASE

By law we must request your permission to use your child’s image, video, or likeness for our print and web-based media productions. Please check the appropriate box as an indicator that you either consent or do not consent to release your child photographs, videos and audio clips.

Check the appropriate box below.

I I hereby grant the St. Croix Montessori School the right to use and reproduce any and all photographs, videos, audio clips taken of my child in conjunction with their involvement as a student in any marketing materials, brochure, flyer, print and electronic publications such as newsletters, social media sites (Facebook, Twitter, & YouTube) and other online/web-based sites.

I do not grant the St. Croix Montessori School the right to use and reproduce any and all photographs, videos, audio clips taken of my child in conjunction with their involvement as a student in any marketing materials, brochure, flyer, print and electronic publications such as newsletters, social media sites (Facebook, Twitter, & YouTube) and other online/web-based sites.

_______________________________________________ __________________ Parent’s Signature Date

The information on this application is correct to the best of your knowledge.

Parent (A) Signature: Date:

Parent (A) Print Name:

Parent (B) Signature:Date:

Parent (B) Print Name:

Advance deposit of $150.00 is applied towards tuition to ensure a space is reserved for your child. St. Croix Montessori is a 501(c)(3) non-profit organization that admits students regardless of race, color, religion, national, or ethnic origin. It does not discriminate in administration of its educational policies, financial aid, athletic or other school administered programs.

For office use only: Date Received________________________________ Rec’d By_________________________________





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