Enrollment Form

* = Required Information

Full Day Montessori Early Learning

Student Information

Last Name *

First Name *

Middle Name

Usual Name if Different from Above

Date of Birth *

Gender *

Male

Female

Child's Home Address *

Postal Code *

Child's Home Phone Number *

Parent/Guardian Information

Mother's Name

Home Phone Number

Work Phone Number

Career

Mobile Phone Number

Home Address

Father's Name

Home Phone Number

Work Phone Number

Career

Mobile Phone Number

Home Address

Person(s) Authorized to Pick Up Child (other than parent/guardian listed above)

Name

Relationship

Cell Phone

Home Phone

Name

Relationship

Cell Phone

Home Phone

Name

Relationship

Cell Phone

Home Phone

Name

Relationship

Cell Phone

Home Phone

Name

Relationship

Cell Phone

Home Phone

Alternate Person(s) to Call in Case of an Emergency

Name

Relationship

Cell Phone

Home Phone

Name

Relationship

Cell Phone

Home Phone

Name

Relationship

Cell Phone

Home Phone

Out of Province Contact Person
Please list at least one out of province contact.
Note: this person will be contacted if there are no local telephone services due to a natural disaster.

Name

Relationship

Cell Phone

Home Phone

Name

Relationship

Cell Phone

Home Phone

Emergency Health Information

Care Card Number

Family Physician

Mobile Number

Clinic Name & Address

Family Dentist

Mobile Number

Clinic Name & Address

Consent for Emergency Care

In the event that my child is injured, ill or in need of immediate attention I, authorize the staff of North Fleetwood Montessori School to seek medical attention and/or admit my child to hospital if I am unable to be contacted or otherwise unable to respond.

Name of Parent/Guardian *

Date Signed *

Child’s Immunization Status
(Please record dates [year/month/day] or attach copy of immunizations)

Are you child’s immunizations up to date?

Yes, immunized

No, not immunized

Diphtheria

Pertussis

Tetanus

Polio

MMR(Measles/Mumps/Rubella)

HIB

Health Information

Does your child have any life threatening allergies?

Yes

Please list any allergies your child may have

Developmental Area

Speech or language development

Yes

Physical Development

Yes

Does your child receive support from the Centre of Child Development?

Yes

Please Describe

Has your child attended preschool or daycare before?

Yes

Please list name of school and how long he/she attended

Family and General Household Information

Please list the names of the significant people in your child’s life

Describe the guidance and discipline methods used at home

Primary Language

Other Languages

Parent/Guardian Providing Information

Print Name *

Date Signed *

Monday	Tuesday	Wednesday
Thursday	Friday