Registration Form

Atlanta Montessori Academy
Application/Registration Form

Student Information:

Child’s Name ________________________________________________________
Last Name First Name Middle Name
Home Address _______________________________________________________

City ______________________________ State _______ Zip __________________

Home Phone:_______________________Work Phone:_______________________

email contact: ________________________________________________________

Date of Birth (MM/DD/YYYY) ____________________________ Age ___________

Gender (M/F) ______ Height ______ Eye Color _________ Hair Color __________

Birthmarks __________________________________________________________

Allergies ____________________________________________________________

Other Pertinent Information:_____________________________________________

Please list any legal judgments regarding custody or welfare of child (include State,
name of judge and a copy of paperwork):___________________________________

____________________________________________________________________

School Term
______ 10 month Montessori

Program Selection
______ Infant Full Day - Only
______ Toddler Half-Day(8:30a - 11:30a)
______ Toddler Full-Day (8:30a - 3:00p)
______ Toddler All-Day (8:30a - 6:00p)
______ Primary Half-Day (8:30a-11:30a)
______ Primary Full-Day (8:30a - 3:00p)
______ Primary All-Day (8:30a - 6:00p)
______ Early-Bird (7:00a - 8:15a)

I give ____ or do not give ____ Atlanta Montessori Academy permission to use pictures of my child in school publications and advertisements.

I give ____ or do not give ____ Atlanta Montessori Academy permission to publish my child’s address and phone number in the school directory for such purposes as birthday party invites and play date coordination.

Parent/Guardian Information:

Legal Guardian’s Name __________________________________________________
Last Name First Name Middle Name

Home Address _________________________________________________________

City ___________________________ State ___________ Zip ___________________

Home Phone _______________________ Work Phone _________________________

Other Contact #s (e.g. cell phone and/or pager) _______________________________

Email _________________________________________________________________

Relationship to child? (Mother, Father, Step-Father, Step-Mother, Legal Guardian) ____________________________

Lives with child (Y/N) _______________

Marital Status? ( ) Married ( ) Single ( ) Divorced ( ) Separated

Employer _____________________ Job Title _______________________________

Employers Address _________________________________________________________

Driver’s License Information (State/#/Exp.) ___________________________---______

Spouse/Partner Name (if applicable)_____________________________________________

Home Address _________________________________________________________

City ________________ State __________ Zip ___________________

Home Phone _______________ Work Phone _____________________

Other Contact #s (e.g. cell phone and/or pager)
______________________________________________________________________

Email _______________________________________________________

Relationship to child? (Mother, Father, Step-Father, Step-Mother) ________________

Lives with child (Y/N) _____

Permission to Pickup child (Y/N) __________

Marital Status? ( ) Married ( ) Single ( ) Divorced ( ) Separated

Employer _____________________ Job Title _______________________________

Employers Address ____________________________________________________

Driver’s License Information (State/#/Exp.) ____________________________---_____

Medical Information:

Student's Name _________________________ Birth Date ______________________

List any medical conditions or allergies to:

Medications ___________________________________________________________

Food / Beverages _______________________________________________________

Other _________________________________________________________________

Indications of onset of allergic reaction or medical situation:

______________________________________________________________________

Actions to be taken at onset:

______________________________________________________________________

Physician's Name _______________________________________________________

Street Address __________________________________________________________

City _____________________________________ State _______ Zip ______________

Phone # __________________________________

Dentist’s Name __________________________________________________________

Street Address __________________________________________________________

City _____________________________________ State _______ Zip ______________

Phone # _________________________________

Hospital Preference ______________________________________________________

Primary Health Insurance Carrier ___________________________________________

Policy # _______________________________________________________________

Secondary Insurance Carrier ______________________________________________

Policy # _______________________________________________________________

Emergency Medical Authorization/Release Information:

In the event of a medical emergency, I/We hereby authorize Atlanta Montessori Academy (AMA) to take whatever measures deemed necessary in supplying medical attention to my child. I/We understand that consistent with the circumstances and available time, AMA will attempt to contact and follow the instruction of the parent(s)/guardian(s). In the event such persons are unavailable or time does not permit contacting them, permission is hereby granted to AMA to contact and follow the instructions of other available medical professionals. I/We also agree to be solely responsible for payment of all associated medical expenses that it may have to incur in helping to provide emergency medical care to the above named child.

Furthermore, if the child's parent(s)/guardian(s) cannot be reached in an emergency, permission is granted to Atlanta Montessori Academy to contact the persons listed below. The following persons and those signing this form are also authorized to pick up the above-mentioned child in the event of an emergency and/or at the end of the school day.

1. Emergency Contact's Name ___________________________________________________

Address _____________________________________________________________________

Home Phone _____________________ Work Phone _______________________

Alternate Phone #s____________________________________________

Relationship to child ___________________________________________

2. Emergency Contact's Name ___________________________________________________

Address _____________________________________________________________________

Home Phone _____________________ Work Phone ________________________

Alternate Phone #s ____________________________________________

Relationship to child ____________________________________________

3. Emergency Contact's Name ___________________________________________________

Address _____________________________________________________________________

Home Phone _____________________ Work Phone _______________________

Alternate Phone #s____________________________________________

Relationship to child ___________________________________________

(Mother/Guardian Signature) ______________________________________ Date ____________ Mother's Current work#____________________

Parent/Guardian Signature ______________________________________ Date ____________ Father's Current work# _____________________

Authorization For Pickup:

Other than the parent(s), listed below are authorized pick up persons:

1. Name ___________________________________________________________
Address ___________________________________________________________
Home Phone __________________________ Work Phone ___________________
Alternate Phone #s, cell etc _____________________________________________
Relationship to child ___________________________________________________

2. Name ___________________________________________________________
Address ___________________________________________________________
Home Phone __________________________ Work Phone ___________________
Alternate Phone #s, cell etc _____________________________________________
Relationship to child ___________________________________________________

3. Name ___________________________________________________________
Address ___________________________________________________________
Home Phone __________________________ Work Phone ___________________
Alternate Phone #s, cell etc _____________________________________________
Relationship to child ___________________________________________________

4. Name ___________________________________________________________
Address ___________________________________________________________
Home Phone __________________________ Work Phone ___________________
Alternate Phone #s, cell etc _____________________________________________
Relationship to child ___________________________________________________

5. Name ___________________________________________________________
Address ___________________________________________________________
Home Phone __________________________ Work Phone ___________________
Alternate Phone #s, cell etc _____________________________________________
Relationship to child ___________________________________________________

Mother/Guardian Signature _______________ Date signed ____________________
Father/ Guardian Signature _______________ Date signed ____________________

Siblings:

Name ________________ D.O.B _____________ School Attending ________________

Other Adults in the home where the child lives _________________________________
Relationship ___________________________ How Often? _______________________

Languages spoken in the home ______________________________________________
Primary Language of the child _______________________________________________

HEALTH:

Allergies ______________________________________________________________
(Food/Beverage, Medication, Other)

Medication(s)__________________________________________________________

Please Check:
Asthma _____ Eye Problems ____ Speech Problems ____
Coicky Baby _____ Headaches ____ Stomach Problems ____
Ear Infections _____ Motor Problems ____ Tubes In Ears ____
Seizures_____

DEVELOPMENTAL MILESTONES:
(At What Age Did Your Child...)

Sit Up ____ Speak First Words ______ Crawl ______
Speak In Sentances _____ Walk _______

PLEASE CHECK all that apply that describes your child most of the time....

Active _______ Cries Easily _______ Patient _______ Adventurous _______
Daydreams _______ Persevering _______ Affectionate_______ Empathetic _______
Prefers To Lead _______ Cautious _______ Extrovert _______
Prefers to Follow _______ Confident _______ Happy _______ Sensitive _______
Cooperative _______ Introvert _______ Young For Age_______ Creative _______
Moody _______

Describe Your Child's Personality
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

EDUCATIONAL / PSYCHOLOGICAL EVALUATIONS (that have been completed)
Please request and/or forward copies of results to Atlanta Montessori Academy

Please Describe your child's learning style...
____________________________________________________________________
____________________________________________________________________

How much time does your child spend with other children?
____________________________________________________________________
____________________________________________________________________

How does your child handle frustration?
____________________________________________________________________
____________________________________________________________________

What approach to discipline do you use?
____________________________________________________________________
____________________________________________________________________

List any discipline problems you may be experiencing at this time
____________________________________________________________________
____________________________________________________________________

How are you handling the problem?
____________________________________________________________________
____________________________________________________________________

How many hours does your child spend watching television?
____________________________________________________________________
____________________________________________________________________

What are your educational goals for your child?
____________________________________________________________________
____________________________________________________________________

How do you see Atlanta Montessori Academy facilitating these goals?
____________________________________________________________________
____________________________________________________________________

What role do you expect to play in facilitating these goals?
____________________________________________________________________
____________________________________________________________________

How do you see yourself participating in Atlanta Montessori Academy's community as a volunteer?
____________________________________________________________________
____________________________________________________________________

Will you be able to attend study groups and parent meetings that are scheduled in the evenings?
____________________________________________________________________
____________________________________________________________________

Parent/Guardian Signature ________________________ Date ___________________

3726 E. Main Street, College Park, Georgia 30337 atlantamontessori.com 404-768-5700