APPLICATION FORM FOR ADMISSION

Student’s Name: ___________________________________________________________________________________

Last Name First Name Middle Name

Date of Birth: ________________________________________ Sex: _________________________________________

Day Month Year

Preference of session: AM only 9:00 AM – 11:30 AM Extended Care Hours 7:30 AM -5:30 PM

PM Only 1:00 PM -- 3:30 PM 3:30 PM – 5:30 PM

Full Day 9:00 AM – 3:30 PM

Address: __________________________________________________________________________

Street, RR No. Unit

___________________________________________________________________________________________________________________________

____________________________________________ Telephone: ___________________________________________________

City Postal Code

Mother’s Name: ______________________________ Occupation: ___________________________________________

Bus. /Off Address: _____________________________Bus. /Off. Phone: ______________________________________

Street, RR No City

Father’s Name: _______________________________ Occupation: __________________________________________

Bus. /Off Address: ____________________________ Bus. /Off. Phone: _______________________________________

Street, RR No City

Emergency Contact: __________________________ Telephone: _____________________________________________

Family Physician: ____________________________ Telephone: _____________________________________________

Physician’s Address: _________________________________________________________________________________

Street, RR No. Unit City

Start Date: ____________________________ End Date: _______________________________

I/We have read the terms and conditions of the school in the agreement statement. I/We agree to admit my/our son at Beaver brook Montessori School.

Parents Signature: ____________________________ Date: ____________________