Admission Form – Madison Montessori Academy

Last Name

First Name

Middle Name

Date of Birth

Male

Female

First Language

Address

Apt Number

City

Province

Postal Code

FAMILY INFORMATION

Parent 1 Last Name

Parent 1 First Name

Address

Home Phone

Work Number Ext.

Cell Phone

Parent 2 Last Name

Parent 2 First Name

Address

Home Phone

Work Number Ext.

Cell Phone

SIBLING INFORMATION

Sibling Name

Male

Female

Date of Birth (D/M/Y)

Sibling Name

Male

Female

Date of Birth (D/M/Y)

Sibling Name

Male

Female

Date of Birth (D/M/Y)

Sibling Name

Male

Female

Date of Birth (D/M/Y)

MEDICAL INFORMATION

Doctor's Name

Doctor's Phone

Allergies

Health History

Immunization Record Given

Yes No

Is there any reason to be exempt from Immunization? If 'Yes' then an exemption form must be completed.

Yes No

Special Conditions

EMERGENCY CONTACT #1 (other than parent)

EMERGENCY CONTACT #2 (other than parent)

Emergency Contact Name 1

Emergency Contact Relationship 1

Emergency Contact Home Phone 1

Emergency Contact Work Phone 1

Emergency Contact Cell Phone 1

Emergency Contact Email 1

Emergency Contact Name 2

Emergency Contact Relationship 2

Emergency Contact Home Phone 2

Emergency Contact Work Phone 2

Emergency Contact Cell Phone 2

Emergency Contact Email 2

DROP OFF/PICK UP INFORMATION (Please indicate other than parents)

Drop off Name 1

Relationship

Phone

Cell Phone

Drop off Name 2

Relationship

Phone

Cell Phone

PROGRAM REQUESTED

Infant Program

Part Time Full Time Schedule A Schedule B

* Please note the part time option for the Infant Program is not always available

Toddler Program

Part Time Full Time Schedule A Schedule B

Casa Program

Part Time Full Time Schedule A Schedule B

Before & After Care

Regular Option Extra Package

Start Date Requested

AUTHORIZATION

Authorization 1

I hereby grant permission for the Program Staff of the Child Care Program to take whatever steps necessary to obtain emergency medical attention in the event that I (parent/legal guardian) cannot be reached. It is also understood that I {parent/legal guardian) shall assume responsibility for any cost incurred.

Authorization 2

I hereby grant permission for my child to leave the licensed premises under the supervision of a staff member for field trips, community walks, etc. I understand that dated, time-limited specific forms will be issued for each field trip.

Authorization 3

I hereby grant permission for my child to use the play equipment and participate in all of the activities of their program at Madison Montessori Academy.

Application for Admission

Student Information