Strata Montessori Adolescent School 2017/2018 Re-Enrolment
This form is for students already enrolled at Strata Montessori Adolescent School who will be returning for the 2017/2018 school year.
Student Information
Last Name
Your answer
First Name
Your answer
Middle Name(s)
Your answer
Preferred Name
Your answer
Date of Birth (yyyy/mm/dd)
MM
/
DD
/
YYYY
Child's Gender:
Home Street Address
Your answer
City/Town
Your answer
Province
Your answer
Postal Code
Your answer
Home Phone
Your answer
Family Information
Parent/Guardian I (with whom the child resides) relation to child:
Your answer
Check if information is the same as previous year.
P/GI Last Name
Your answer
P/GI First Name
Your answer
P/GI Employer
Your answer
P/GI Occupation
Your answer
P/GI Work Phone
Your answer
P/GI Mobile Phone
Your answer
P/GI Primary Email Address
Your answer
___________________________________________________________________
Parent/Guardian II relation to child
Your answer
P/GII Last Name
Your answer
P/GII First Name
Your answer
P/GII Employer
Your answer
P/GII Occupation
Your answer
P/GII Work Phone
Your answer
P/GII Mobile Phone
Your answer
P/GII Primary Email Address
Your answer
If different from student address, please provide address below:
Your answer
Parents' Marital Status
Your answer
Sibling Information
Please provide the name, birthdate, and 2016-2017 school of each sibling.
Sibling 1 Name
Your answer
Sibling 1 Birthdate (yyyy/mm/dd)
MM
/
DD
/
YYYY
Sibling 1 2016-2017 School
Your answer
Sibling 2 Name
Your answer
Sibling 2 Birthdate (yyyy/mm/dd)
MM
/
DD
/
YYYY
Sibling 2 2016-2017 School
Your answer
Sibling 3 Name
Your answer
Sibling 3 Birthdate (yyyy/mm/dd)
MM
/
DD
/
YYYY
Sibling 3 2016-2017 School
Your answer
Emergency Contact Information
Please list the names of two persons other than the parents or guardians who may be contacted in the event of an emergency.
Check if contact information is the same as previous year.
Primary Emergency Contact
Primary Contact Name
Your answer
Primary Contact Relation to child
Your answer
Primary Contact Home Phone
Your answer
Primary Contact Work Phone
Your answer
Primary Contact Mobile Phone
Your answer
Secondary Emergency Contact
Secondary Contact Name
Your answer
Secondary Contact Relation to child
Your answer
Secondary Contact Home Phone
Your answer
Secondary Contact Work Phone
Your answer
Secondary Contact Mobile Phone
Your answer
Authorized Pick-up Information
Please list the names of two persons other than the parents or guardians who may pick up.
Check if pick-up information is the same as previous year.
Primary Pick-up Person
Primary Pick-up Name
Your answer
Primary Pick-up Relation to child
Your answer
Primary Pick-up Home Phone
Your answer
Primary Pick-up Work Phone
Your answer
Primary Pick-up Mobile Phone
Your answer
Secondary Pick-up Person
Secondary Pick-up Name
Your answer
Secondary Pick-up Relation to child
Your answer
Secondary Pick-up Home Phone
Your answer
Secondary Pick-up Work Phone
Your answer
Secondary Pick-up Mobile Phone
Your answer
Health Information
Check if health information is the same as previous year.
Family Doctor
Your answer
Doctor Phone
Your answer
Child's Health Card Number
Your answer
Please list any allergies or other health concerns and issues your child may have, their reaction to their allergies, and any plans, accommodations, or responses to allergy and/or health issues that Strata should know about:
Your answer
Contract Agreement
We the parent(s) / guardian acknowledge the following: 1.Payment in full or by post-dated cheques payable to Strata Montessori Adolescent School is enclosed. Our child is enrolled upon acceptance by Strata until he/she completes the program, subject to the Strata’s right to request withdrawal of a student if withdrawal is to the benefit of the school as a whole. 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 Strata immediately of any changes. We understand that the responsibility of Strata for our child begins when the child has been duly admitted to Strata 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, Strata is hereby authorized to contact the physician named above, or a physician selected by Strata, to treat, hospitalize and order injections, anaesthesia, or surgery for our child. We understand that Strata will notify us of field or program trips and Odysseys. We understand the school will use school transportation, hired transportation, or volunteer transportation by teachers or parents for these excursions. We also accept that children, even under close supervision, will have occasional accidents. Therefore, we hereby release, indemnify,and hold harmless Strata Montessori Adolescent 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 Strata, its directors, agents, or employees, or are entirely beyond the control of Strata, its directors, agents, or employees.
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