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DVMS 2019-2020 Enrolment Form
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A Montessori Morning.
A 3 hour Montessori work cycle at DVMS.  (C) Lindsay Palmer Photography: http://www.lindsaypalmer.ca 
Student Information
Student Last Name: *
Student First Name: *
Student Middle Name(s): *
(enter "none" if no middle name)
Student Preferred Name:
Student Birthdate: *
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Student Gender: *
Student Citizenship Status: *
Country of Birth: *
Primary Spoken Language: *
Other Languages Spoken:
Primary Home Street Address: *
City: *
Province: *
Postal Code: *
Primary Home Phone Number: *
Name of Previous School (if applicable): *
If no previous school, please enter "none"
Previous School Address:
Previous School Phone:
Previous School Principal's Name:
Learning Differences: *
Has your child been diagnosed with a learning difference(s)? If so, please let us know what was diagnosed (if no diagnosis, please enter "N/A"
Assessments and/or referrals? *
Has your child participated in, or been referred/recommended for, a psycho-educational assessment or any other related testing or assessments (ex. speech therapy, occupational therapy, etc.). If yes, please let us know what type of testing and if any follow-up services have been initiated. If no, please enter "N/A".
Tutoring and Other Instruction: *
Has or does your family take advantage of any private tutoring or other individualized instruction services? If yes, please provide details. If no, please enter "N/A".
Has an Individualized Education Plan (I.E.P.) Been Created for Your Child? *
Required
Family History
Is there any family history that you are willing to share that may help us create and maintain the best developmental learning environment for your child (ex. dyslexia, ADHD, or other learning challenges).
Desired Programme
Please Select a Programme: *
Start Date: *
Payment Option: *
Do you intend to submit payment in full or in quarterly installments?
Required
Would you like to enrol your child in our Hot Lunch program? *
Please see http://dvms.ca/fees-forms/hot-lunch-registration-form for more information. PLEASE NOTE: If you are registering for the Toddler program, you MUST enrol in the hot lunch program per provincial legislation; also, any Casa level child under the age of 3 years and 8 months must be enrolled in the Hot Lunch program unless the school receives from you a documented exemption for dietary reasons. Please call the school if you have any questions.
Required
Family Information
Parent/Guardian I
With whom the child resides.
Last Name: *
First Name: *
Relation to Child: *
Home Phone: *
Should be same as "Primary Home Phone Number" above.
Cell Phone:
Work Phone: *
If you work from home, please enter "Home"
Employer: *
If you work as a stay-at-home parent, please enter "Parent at home"
Occupation: *
If you work as a stay-at-home parent, please enter "Parent at home"
Work Address: *
If you work from home, or work as a stay-at-home parent, please enter your home address.
Primary Email Address:
Please provide the best email address for DVMS to contact you.
Parent/Guardian II
II Last Name:
II First Name:
II Relation to Child:
II Home Phone:
II Cell Phone:
II Work Phone: *
If you work from home, please enter "Home"
II Employer: *
If you work as a stay-at-home parent, please enter "Parent at home"
II Occupation: *
If you work as a stay-at-home parent, please enter "Parent at home"
II Work Address: *
If you work from home, or work as a stay-at-home parent, please enter your home address.
II Primary Email Address:
Please provide the best email address for DVMS to contact you.
If Parent/Guardian II address is different than student's address, please provide below:
Parent's Marital Status: *
Sibling Information
Sibling 1 Name:
Sibling 1 School:
Sibling 1 Date of Birth:
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Sibling 2 Name:
Sibling 2 School:
Sibling 2 Date of Birth:
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DD
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YYYY
Sibling 3 Name:
Sibling 3 School:
Sibling 3 Date of Birth:
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YYYY
Emergency Contact and Authorized Pick-Up Information
Primary Emergency Contact & Authorized Pick-up Information:
Please enter emergency contact information in sequential order of who you would like us to contact first in a situation where we cannot get in touch with you.
Emergency Contact 1 Name(s): *
Please enter full first and last name, and any grandparent nickname (nona, nanny, etc.)
Emergency Contact 1 Relation to Child: *
Emergency Contact 1 Home Phone: *
(enter "none" if cell only)
Emergency Contact 1 Work Phone: *
(enter "none" if no work phone)
Emergency Contact 1 Cell Phone: *
(enter "none" if no cell phone)
1 Authorized for Pick-up? *
Is your first emergency contact also authorized by you to be an alternative pick-up for your child?
Secondary Emergency Contact & Authorized Pick-up Information:
Emergency Contact 2 Name(s): *
Please enter full first and last name, and any grandparent nickname (nona, nanny, etc.)
Emergency Contact 2 Relation to Child: *
Emergency Contact 2 Home Phone: *
(enter "none" if cell only)
Emergency Contact 2 Work Phone: *
(enter "none" if no work phone)
Emergency Contact 2 Cell Phone: *
(enter "none" if no cell phone)
2 Authorized for Pick-up? *
Is your second emergency contact also authorized by you to be an alternative pick-up for your child?
Other Alternative Pick-ups? *
Please provide the Name, Relation to Child, and Cell Phone (preferred) Contact Number of any other people you are authorizing to pick up your child from DVMS.
Health Information
Family Doctor Name: *
Family Doctor Phone: *
Student Health Card Number (including version code): *
Please list any allergies your child has, including reactions to the allergies. If your child has a serious or life-threatening allergy, please request an allergy alert form from the DVMS office, provide two current Epi-Pens, and sign our Anaphylaxis Policy.
Please list any food sensitivities and/or restrictions:
Please indicate any social, emotional, or medical conditions your child has:
Is your child being administered medication on a regular basis? *
If "Yes" to medication please provide details:
Does your child have any physical limitations that require accessibility accommodations, or that may prevent participation in sports or other physical activities?
Clear selection
If "Yes" to limitations please provide details:
Sunscreen and other creams: *
Due to the frequency and their longer term daily usage, sunscreen, diaper creams, lip balms, and hand sanitizers can have a blanket authorization from a parent on the enrolment form and can be administered without a medication form as long as they are non-prescription and/or they are not for acute (symptomatic) treatment, whether they have a drug administration number (DIN) or not. Please select below if you would like to provide blanket authorization for the administration, or self-administration for Elementary-level children, of the above items.
Please provide any other health information that you feel would be helpful or that you would like to share:
Additional Information
What would you like to tell us about your child?
Why are you considering a Montessori education for your child?
List any specific goals you would like to see your child acquire at school:
What activities do you do as a family?
What activities does your child enjoy?
Has your child been away from you for an extended period of time in the past? Please describe:
Has your child attended programs in a previous school, daycare, or with a care provider? Please describe:
Contract Agreement
Please read. You will be required to provide your signature on the hard copy version of this form indicating that you consent and agree to the following terms.
We the parent(s)/guardian(s) of ____________ acknowledge the following:

1.Payment in full or by post-dated cheques payable to Dundas Valley Montessori School is enclosed. Our child is enrolled upon acceptance by the School until he/she completes the program, subject to the School’s right to request withdrawal of a student if withdrawal is to the benefit of the School as a whole or a specific Montessori environment/classroom.

2.There is no refund or reduction in fees in case of withdrawal, dismissal, absence, cancellation, or non-attendance.

3.We confirm the information given in the application form and agree to notify the School immediately of any changes. We understand that the responsibility of the School for our child begins when the child has been duly admitted to School each day and ends when the child has been dismissed to go home. To the best of our knowledge, our child is in good health. If we cannot be reached at a time of illness or accident, or if the emergency is such that the time does not permit such contact, the School is hereby authorized to contact the physician named above, or a physician selected by the School, to treat, hospitalize and order injections, anaesthesia or surgery for our child. We understand that the School will notify us of field or program trips using School transportation, hired transportation or volunteer transportation by teachers or parents. We also realize that young children, even under close supervision, will have occasional accidents.Therefore, we hereby release, indemnify and hold harmless the School, its directors, agents or employees from any and all claims, damages or other liabilities for injuries to our child which are not a result of the negligence of the School, its directors, agents or employees, or are entirely beyond the control of the School, its directors, agents or employees.

4.There is a hot lunch program available. It is required by the Child Care and Early Years Act that a child who is under 3 years and 8 months as of the first day of school and stays for lunch must participate in the hot lunch program. I agree to enrol them into the hot lunch program offered by the school and submit payment for this program as required by administration. If it is not required and I choose not to join the hot lunch program then I will provide my child(ren) with a nutritious, well balanced meal providing the child with all of the nutrients required to maintain health and encourage proper growth according to Canada’s Food Guide.

5. Dundas Valley Montessori School uses email and other means electronic telecommunication to distribute information about the school and it's activities. In accordance with Canada's anti-spam legislation, we require your permission to communicate with you via email or other means of electronic telecommunications. By signing this contract agreement, you are providing Dundas Valley Montessori School with consent to communicate with you via electronic means of telecommunications. If, at any time, you wish to revoke this consent, please state such intention in writing to the DVMS office.
 
Field Trip Waiver *
The undersigned hereby releases Dundas Valley Montessori School, its owners, directors and employees of any and all claims whatsoever arising or which may arise by reason of the Child’s participation in any Field Trip occurring during the school year due to personal injuries or illness, excepting any such claims resulting and/or arising out of the gross negligence of Dundas Valley Montessori School, its owners, directors, and employees. From time to time the children go on impromptu nature walks and visits to the grocery store, library, etc. Should the Child suffer injury or illness while on the Field Trip, and a parent or guardian is not present, the undersigned authorizes any representative of Dundas Valley Montessori School to authorize such medical attention for the Child as may be deemed appropriate by said representative of Dundas Valley Montessori School in the circumstances. The undersigned also agrees to maintain appropriate medical insurance coverage for the Child while on the Field Trip.The undersigned hereby releases Dundas Valley Montessori School, its owners, directors, and employees of any and all claims whatsoever arising out of any medical treatment the Child might require. I have carefully read this Waiver and permission Agreement and understand the terms and conditions of it and agree to be bound thereby.
Required
Permission to take and Publish Photographs and Videos *
I understand and authorize that pictures and videos taken by Dundas Valley Montessori School may be used for promotion (i.e. for articles in newspapers, reviews, parent newsletters, marketing brochure, website, social media, parent handbook, etc.). Names or other identifying elements are never published. Please check the appropriate box below:
Required
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