APPLICATION - Montessori School St. Clair

MONTESSORI SCHOOL ST. CLAIR

2360 Country Road, Belleville IL 62221

APPLICATION FORM

618-235-4289

APPLICATION IS FOR __________________________________________________

DATE OF BIRTH _________SEX ________ TELEPHONE _______________

HOME ADDRESS ______________________________________________________CITY __________________STATE _________ ZIP _____________

PARENT/GUARDIAN #1 NAME__________________________________________________________

RELATIONSHIP TO STUDENT_____________OCCUPATION____________

CELL PHONE____________ EMAIL ADDRESS_______________________________

PARENT/GUARDIAN #2 NAME________________________________________________

RELATIONSHIP TO STUDENT________OCCUPATION_________

CELL PHONE_____________EMAIL ADDRESS______________________________

DESIRED ENTRANCE DATE ___________________________________________________

HAS YOUR CHILD HAD PREVIOUS SCHOOL EXPERIENCE (please describe)_____________________________________________________________________

Is your child’s Immunized?_______________ (All students must be immunized to attend our school as of September 2017)

Does your child display any mental, physical or behavioral issues that we may need to be aware of:_______________________________________________________

What is your child’s prior school or Day Care experience? ___________________________

How did you hear about our school?_______________________

Who may we thank for referring you?__________________________

Please return this application fee accompanied by a check for $25.00 payable to Montessori School St. Clair. This is a non-refundable application fee.

SIGNATURE PARENT/GUARDIAN #1 ____________________DATE __________________

SIGNATURE PARENT/GUARDIAN #2 ____________________DATE __________________