Renaissance Village Montessori

Renaissance Village Montessori Registration Form

Renaissance Village Montessori Registration Form
Student First Name*
Student Last Name*
Birth Date*
Date Format: MM slash DD slash YYYY
Gender*
- Male
- Female
Address*
Street Address City State / Province / Region ZIP / Postal Code
List any existing medical conditions, medication and/or special attention your child may require?
Allergies
Pediatrician's Name*
Pediatrician's Phone*
Pediatrician's Address*
Permission to Photograph or Videotape
Can we get your permission to use photographs or video of your child as a form of documentation of our work? These photos may be used on the bulleting boards, on our website or in our newsletter. We will never reference your child by name of provide any specific information regarding your child. We use photos exclusively for the purpose of furthering the educational mission of Renaissance and teacher/parent training?*
- I grant you permission
- I do not grant you permission
Parent/Guradian Information
Parent/Guardian #1 Name*
Relationship*
Mobile Phone*
Work Phone
Home Phone*
Email*
Parent/Guardian #2 Name*
Relationship*
Mobile Phone*
Work Phone
Home Phone
Email*
Marital Status:*
- Married
- Single
- Divorced
- Separated
- Widowed
If grandparents are involved in the child's life please list their names:
Name Place of residence (city, state)
Family Information
Does your child live with both parents?
- Yes
- No
If No which is the custodial parent?
- Mother
- Father
Please describe the visitation arrangements
Describe the level of grandparents' involvement
Does your child have siblings?*
- Yes
- No
If Yes, list their names and DOBs.
Name DOB
Program & Schedule
Choose program:*
- Montessori Beginnings 16 - 24 months
- Toddler 24 - 36 months
- Primary 3 - 5 years
Emergency Contacts & Authorized Pickup Persons:
1st Contact/Pick up Name
Relationship to the Child
Phone
Able to pick up child?
- Yes
- No
2nd Contact/Pick up Name
Relationship to the Child
Phone
Able to pick up child?
- Yes
- No
3rd Contact/Pick up Name
Relationship to the Child
Phone
Able to pick up child?
- Yes
- No
4th Contact/Pick up Name
Relationship to the Child
Phone
Able to pick up child?
- Yes
- No
Important note: In order to pick up your child your caregiver must present a valid picture ID
Medical care authorizations (must check both)
- In an emergency Renaissance Village staff has my permission to call an ambulance or to take my child to any available physician or hospital.
- In an emergency Renaissance Village staff has my permission to obtain medical treatment for my child except these restrictions, if any:
Additional Comments & Information:
Is there any other information that would be helpful to our management and teaching staff? (child's fears, special words and their meanings, likes and dislikes)
Parent Signature*
Date*
Date Format: MM slash DD slash YYYY

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Name	Place of residence	(city, state)

Name	DOB

Renaissance Village Montessori

Renaissance Village Montessori Registration Form

Permission to Photograph or Videotape

Parent/Guradian Information

Family Information

Program & Schedule

Emergency Contacts & Authorized Pickup Persons:

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