Rockland Montessori Academy For Young Learners

CHILD'S FACE SHEET/ENROLLMENT FORM

Child's Name: ________________________________________________________________________________________

Date of Birth: _____________________ Place of Birth (City)____________________________________________________

Home Address: _______________________________________City_____________________________Zip_____________

Telephone: __________________________________________________Primary Language __________________________

Child's Identifying Information (required by Department of Early Education and Care regulations:)

Eye Color:___________________Hair Color:___________________Skin Color:___________________Sex:______________

Height:______________Weight:______________Identifying Marks:____________________________________________

Allergies:___________________________________________________________________________________________

PARENT/GUARDIAN INFORMATION:

Name:___________________________________________Name:_____________________________________________

Relationship to Child:_______________________________Relationship to Child:_________________________________

Home Address:____________________________________Home Address:______________________________________

Home Phone:______________________________________Home Phone:_______________________________________

Cell Phone:________________________________________Cell Phone:_________________________________________

Business /Occupation:_______________________________Business/Occupation:_________________________________

Address:_________________________________________Address:___________________________________________

Phone:_______________________Hours_______________Phone:__________________________Hours:_______________

If parents cannot be contacted, notify: (You must list at least two names, NOT parents; include on emergency release form)

Name:____________________________________________Name:______________________________________________

Address:_________________________________________Address:____________________________________________

Phone:___________________________________________Phone:______________________________________________

Relationship to Child:________________________________Relationship to Child:___________________________________

Others in family________________________________________________________________________________________

Child's Physician/Clinic_______________________________________________Phone______________________________

Parent/Guardian Signature______________________________________________________Date______________________