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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 | Page 1 of 6
3013 Orange GroveChristiansted, VI 00820
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 #______________________
Contact #2: ________________________________________ Relationship____________________________
Primary Phone #__________________________________ Secondary Phone #_____________________
Contact #3: ________________________________________ Relationship____________________________
Primary Phone #_____________________________________ Secondary Phone #____________________
Contact #4: ________________________________________ Relationship____________________________
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
Revised March 2017 | Page 2 of 6
3013 Orange GroveChristiansted, VI 00820
www.stcroixmontessori.com
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.
Revised March 2017 | Page 3 of 6
3013 Orange GroveChristiansted, VI 00820
www.stcroixmontessori.com
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
Revised March 2017 | Page 4 of 6
3013 Orange GroveChristiansted, VI 00820
www.stcroixmontessori.com
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:
Revised March 2017 | Page 5 of 6
3013 Orange GroveChristiansted, VI 00820
www.stcroixmontessori.com
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_________________________________
Revised March 2017 | Page 6 of 6
3013 Orange GroveChristiansted, VI 00820
www.stcroixmontessori.com