Application

Enrollment Application

Please complete the registration form below.

Step 1 of 6

Child's Name *

First

Last

Child's Nickname: *

First

Last

Date of Birth:

Sex

Address

Address Line 1

Address Line 2

City

State

Zip Code

Health and Development Information

Please list any chronic physical problems, pertinent developmental information, and/or, special accommodations needed

Previous Child Day Care Programs and Schools Attended

Additional School/Program

If child attends Lewinsville Montessori AND another school/program please enter the name of that here.

Grade or Class Level

Requested Start Date (space permitting)

Referred By: (if applicable)

Allergies or Intolerance to Food, Medication, etc. and Action to Take in an Emergency

Child's Physician

Physician Phone #

Emergency Contact Person 1 *

First

Last

Please include the name and information below of an emergency contact if parent(s) cannot be reached.

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Relation to child *

Emergency Contact Person 2

First

Last

Please include the name and information below of an emergency contact if parent(s) cannot be reached.

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Relation to child

Person(s) Authorized to Pick Up Child *

Please list the person(s) authorized to pick up child. Include names and relationship to parents/child

Person(s) NOT Authorized to Pick Up Child

Appropriate paperwork such as custody papers shall be attached if a parent is not allowed to pick up the child. NOTE: Section 22.1-4.3 of the Code of Virginia states that unless a court order has been issued to the contrary, the noncustodial parent of a student enrolled in a public school or day care center (i) shall not be denied the opportunity to participate in any of the student's school or day care activities in which such participation is supported or encouraged by the policies of the school or day care center solely on the basis of such noncustodial status and (ii) shall be included, upon the request of such noncustodial parent, as an emergency contact for the student's school or day care activities.

File Upload

Click or drag a file to this area to upload.

If applicable, please upload appropriate paperwork such as custody papers if there are persons NOT authorized to pick up child.

The child day center agrees to notify the parent(s)/guardian(s) whenever the child becomes ill, and the parent(s)/guardian(s) will arrange to have the child picked up as soon as possible if so, requested by the center.
The parent(s)/guardian(s) authorize the child day center to obtain emergency medical care if any emergency occurs when the parent(s)/guardian(s) cannot be located immediately. **
The parent(s)/guardians agree to inform the center within 24 hours or the next business day after his child or any member of the immediate household has developed a reportable communicable disease, as defined by the State Board of Health, except for life threatening diseases which must be reported immediately.
The parents(s)/guardians agree to read and abide by the Infection Control Policy for the protection of their child(ren) as well as other children and staff members of Lewinsville Montessori.
Photo Use Policy (strike through if you DO NOT agree) I authorize Lewinsville Montessori to transmit photos, facsimiles, videos, and likenesses of my child(ren) in school publications, advertisements, and website. No reference will be made to name or address, and these will never be used for resale.
Photo Transmission (strike through if you do not agree) I authorize Lewinsville Montessori to transmit photos, facsimiles, videos, and likenesses to us, the parent(s)/guardian(s) via e-mail, text message, and HiMama application.
Rule, regulations, policies, and procedures, as outlines in the Parent Handbook are understood and accepted as a condition of enrollment.
I understand that it is my sole responsibility to update and/or keep the administration of Lewinsville Montessori informed of any changes to information (i.e., contact, insurance, transportation).
If EGF Rising Child Development Inc. d/b/a Lewinsville Montessori (“Lewinsville Montessori”) prevails in any litigation at law or in equity, arbitration, or court proceedings, either legal, administrative, or otherwise arising out of or in connection with the enrollment agreement or for the enforcement of its Parent Handbook, policies, or procedures, Lewinsville Montessori shall be entitled to reasonable attorney’s fees, costs, and expenses.

** If there is an objection to seeking emergency medical care, a statement should be obtained from the parent(s) or guardian(s) that states the objection and the reason for the objection.

Child's Full Name *

Name of Parent Signing *

Signature *

Today's Date *

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