Montessori Children s House Registration Form. Child s Name: Start date: Place of Employment. Place of Employment

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1 Montessori Children s House Registration Form Child s Name: Start date: Date of Birth: Nickname: Mother s Name: Mother s Address: Contact Numbers Place of Employment Work Address Work Phone Social Security #: Father s Name: Father s Address: Contact Numbers Place of Employment Work Address Work Phone Social Security #: Emergency Contact Names, Addresses and Phone Numbers (besides parents) Please indicate the hours and days your child will be attending. Monday Tuesday Wednesday Thursday Friday I understand that should I need to change attendance days and/or hours I will contact the Director in writing 2 weeks before doing so or be responsible for my current tuition rate. I understand no refund for supply fees will be given when changing attendance dates. **Make-up days due to holidays, illnesses or other reasons for absences are not permitted. **I also understand that a late fee will be assessed if I am late with tuition, supply payments and I will be billed for pick-up times if I arrive later than my scheduled pickup time. Please list any allergies and side effects your child may have to food, medicine, etc. Please list any medicine, prescription or over the counter that your child takes regularly. 1

2 Enclosed is a non-refundable check in the amount of $ The registration fee is due annually upon your child s initial enrollment date. Parent Signature: Date: Emergency Information Name of Doctor/Clinic: Phone: Name of Dentist: Phone: ALLERGIES (food, medicinal, environmental) If none known please check here: Action to be taken in an emergency: (if left blank, MCH policy is to contact 911 then parents as soon as humanly possible) Please list at least two people (beside parents) to be contacted in an emergency if the parents are not able to be reached. Department of Social Services requires full names, phone numbers, and addresses of each person listed below. 1. Name: Address: Home Phone: Cell Phone: 2. Name Address: Home Phone: Cell Phone: Persons Authorized to Pick-Up Your Child(i.e. carpool drivers, play dates, etc) Please be sure to inform your authorized persons they will need a photo id with them when picking up. 1. Name: Phone: 2. Name: Phone: 3. Name: Phone: Persons not authorized to pick up your child Please provide MCH with a copy of the legal documentation, i.e. court order, if the parent is not permitted to pick-up the child or have any visitation with the child. 2

3 1. 2. LSCLARK, INC. DBA Montessori Children s House Tuition Payment Agreement I/We understand that tuition should be paid on the first school day of every month. I/We understand and agree that if payment is not received by the 5 th of every month my account will be charged a $25.00 late fee. MCH II reserves the right to refuse any parent/child to attend MCH II or participate in any MCH II program if account is in arrears. initials Additionally I/We understand that during the school year tuition charges still apply when: 1. The school is closed for holidays, inclement weather, absences due to illness or for voluntary reasons (i.e. vacations), and in-service days that include Parent/Teacher Conferences or staff training. 2. Tuition is not pro-rated due to any of the aforementioned. Initials I/We understand and agree to pay a $25.00 charge for each returned check. Payment thereafter may be required to be paid by cash, money order or by credit cards. Initials I/We agree to give two weeks advance written notice when withdrawing my child or pay one month of full tuition in lieu of written notice, regardless of the reason for withdrawal during the official school year, September through June. Initials In the event that tuition is not paid and your account is delinquent, I/We agree to pay any and all collection and court costs that MCH II has incurred in order to collect the debt owed. Initials. Initials I/We the undersigned have read, fully understand and agree to abide by the terms and conditions of this Tuition Agreement. Print Child s Name Signature of Parent(s)/Guardian(s) Print Name: Parent(s)/Guardian(s) Date 3

4 Montessori Children s House Agreements 1. The parent(s) and/or guardian(s) give authorization for Child s Name to participate in field trips that Montessori Children s House II attends. Yes No. In the event that you do not wish your child to participate in MCH II field trips the parent(s) and/or guardian(s) agree to keep the child at home the day of the field trip.. Initials 2. Montessori Children s House agrees to notify the parent(s) and/or guardian(s) whenever the child becomes ill or exhibits symptoms that are not common for the child. If the parent(s) and/or guardian(s) are not able to be contacted, MCH II will contact the emergency contacts listed on the child s form. We ask that your child be picked up as soon as possible if they are ill. Parent(s) and/or guardian(s) understand and agree that your child will not be allowed to attend school the following day without a nurse or doctor s note stating they are healthy and well enough to attend if they were sent home due to a fever, contagious illness or disease. 3. The parent(s) and/or guardian(s) agree to inform MCH II within 24 hours after his/her child or any member of the immediate household has developed any reportable communicable disease (i.e. Strep throat, pink eye, etc) as defined by the State Board of Health, except for life threatening diseases which must be reported immediately. 4. Parent(s) and/or guardian(s) give MCH II authorization to seek emergency medical care, transportation, and/or treatment for your child in the event you are unable to be reached or available at the time of the emergency. Signature of Parent(s) and/or guardian(s) Date Administrator of the School signature Date 4

5 Montessori Children s House Emergency Medical Authorization Parent(s) and/or legal guardian(s) of Child s Name give consent and authorizes Montessori Children s House staff to obtain immediate medical care, hospitalization, performance of necessary diagnostic testing, surgery, and/or administration of drugs to the above named child should an emergency occur. It is understood that this consent would only apply to true emergency situations and only when the parent(s) and/or guardian(s) are not able to be reached. Montessori Children s House will notify parent(s) and/or guardian(s) as soon as humanly possible should an emergency occur. 1. I/We will be responsible for payment of medical and/or transport expenses. Initials 2. Medical treatment costs are and will be covered by parents of enrolled child Initials by: Insurance provider: If no insurance, please indicate above. Child s physician and clinic: Physician s Phone #: Child s dentist and phone #: Signature: Print Name: Date: This form will accompany the short form and will be taken on all field trips and outings. 5

6 Montessori Children s House 700 Hillingdon Court Virginia Beach, VA Medical Agreement Form I/We give Montessori Children s House permission to Parent/Legal guardian name administer the following medicine(s) to my child for treatment of medical condition I understand that MCH Staff have only basic training such as CPR and First Aid. There is not any medical staff present and should an emergency occur that 911 will be called first then the parent/legal guardian as soon as humanly possible. Should this happen I will be responsible for all medical costs and transport. (initials) I am aware that my child s name, medical condition and medicine prescribed will be posted in a conspicuous place at Montessori Children s House where other people beside the staff members would be able to see this information. Parent/Legal Guardian Signature: Print Name: Date: 6

7 Previous school or program attended: Dates of attendance: Reason for withdrawal: If the child attends MCH and will also be attending another program, please list the name, contact person and phone number. Name of Facility: Address: Contact Person: Birth certificate #: Phone: FOR SCHOOL USE ONLY BELOW THIS LINE Name of Mother: Name of Father: Date of Birth: Date of Issue: Other form for proof of identity that may be accepted: passport, birth letter from hospital, placement agreement. Licensing Regulations state that MCH needs to see the original document. Photocopies of any of the above including the birth certificate cannot be accepted. 7

8 LSCLARK,INC. d.b.a. Montessori Children s House Advertising Permission Form Please sign and date below if you give LSCLARK,INC d.b.a. Montessori Children s House permission to use any photos of your child taken while in attendance at MCH or while participating in any outside activities (field trips) to use in print and/or other forms of advertising such as internet, newsletters, postcards, etc. We as well as many parents help MCH take photos, therefore, we can not guarantee which photos or which children will be used in our advertising. Children will not be identified by name and no other personal information regarding the child or children will be used. Yes, I give my permission for LSCLARK, INC d.b.a. Montessori Children s House II to use any pictures taken of my child while in attendance at MCH II for advertising purposes as well as to use for the school s website and newsletter. I understand that these photos may be used in online advertisement and/or print media such as postcards or other forms of print advertisement. I realize there is no monetary value associated with the use of these photos. No, I do not give my permission for LSCLARK,INC. d.b.a. Montessori Children s House II to use any photos of my child for advertisement purposes or to use for the school s newsletter or website. Parent Signature: Child s Name: Date: 8

9 COMMONWEALTH OF VIRGINIA CERTIFICATE OF RELIGIOUS EXEMPTION Name Birth Date Student I.D. Number The administration of immunizing agents conflicts with the above named student's and my religious tenets or practices. I understand, that in the occurrence of an outbreak, potential epidemic or epidemic of a vaccine-preventable disease in my child's school, the State Health Commissioner may order my child's exclusion from school, for my child's own protection, until the danger has passed. Signature of parent/guardian/student Date I hereby affirm that this affidavit was signed in my presence on This Day of Notary Public Seal Form CRE-1; Rev. 00/92 9

10 Pre-School: 3 Day Programs 8 a.m. until Noon: $ a.m. until 12:45 p.m. $ a.m. until 3:00 p.m. $ a.m. until 4:00 p.m. $ a.m. until 5:00 p.m. $ a.m. until 6:00 p.m. $ 435 Pre-School: 5 Day Programs 8 a.m. until Noon $ a.m. until 12:45 p.m. $ a.m. until 3:00 p.m. $ a.m. until 4:00 p.m. $ a.m. until 5:00 p.m. $ a.m. until 6:00 p.m. $ 724 Kindergarten: 8 a.m. until Noon $ a.m. until 12:45 p.m. $ a.m. until 3:00 p.m. $ a.m. until 4:00 p.m. $ a.m. until 5:00 p.m. $ a.m. until 6:00 p.m. $ 724 First Grade & Second Grade: 8 a.m. until 3:00 p.m. $ a.m. until 4:00 p.m. $ a.m. until 5:00 p.m. $ a.m. until 6:00 p.m. $ 752 Montessori Children s House Tuition Rate Sheet School Year All Rates are on a monthly basis 10

11 Montessori Children s House School Calendar Sept. 8 First day of school Nov. 11 School Closed Veteran s day Nov Nov. 27 School Closed Thanksgiving Holiday Dec. 1 Dec. 9 Dec 23 Dec. 24 Jan. 2 Progress Reports Issued for all Christmas Program Central Library Auditorium Closing at noon School Closed 7 p.m. until 8 p.m. Christmas/Winter Holidays Jan. 18 School Closed Martin Luther King Day Feb. 15 School Closed to students Parent/Teacher Conferences for K 2 nd grade Pre-school by scheduled conference only March 25 April 1 School Closed Easter/Spring Holiday May 30 School Closed Memorial Day June 15 Last day of School Normal operating hours June 16 End of the Year Ceremony Time & Location TBD June 30 Progress Reports Issued for all June 20 First Day of Summer Session Please note any inclement weather delays or closures will be announced on Channel 13. MCH does not always follow VBPS delays and closures. Provided we are able MCH will also send out text, and Facebook status regarding any delay or closure. Any delays would be from 8 a.m. For instance a two hour delay would mean school begins at 10 a.m. No early morning care would be available. 11

12 Montessori Children s House Supplies Fee Fees are due by the end of October and the end of February 3 mornings only $140 3 full days $180 5 mornings only $180 5 full days $240 Kindergarten: Half Day $180 Kindergarten-3 rd grade: All Day $240 These fees go towards bus rentals, keep field trip tickets to a minimum, festivities, parties, and the purchase of school supplies throughout the year. 12

13 Agreement of Parent Handbook Please sign and return this statement to the school office after reading the Parent Handbook. This statement will be kept with your child s enrollment forms. If there are any questions about the Parent Handbook or would like to discuss the handbook further, please speak with Teacher Lisa or Teacher Melissa. You may contact the school at or e- mail us at We would be happy to arrange a time to answer your concerns or questions. I have read and agree to follow Montessori Children s House Parent Handbook, Agreements in my child s registration forms and Emergency Plan. I understand that my child(ren) is registered for a full academic year, September through mid June (as per school calendar provided in your child s registration forms) If a withdrawal is necessary during this time for any reason, I agree and will provide Montessori Children s House with at least 14 days written notice prior to withdrawal. If I do not give 14 days written notice I understand that I/we will be responsible for the following month s tuition. Parent/Guardian Signature: Date: Print Name: /Print Child s Name: 13

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