Child Enrollment Form

Child Enrollment Form

Please complete this form for each child enrolled. Return with your $100.00 non-refundable registration fee to Ferial Moawad or mail to St. Mark Christian Montessori Preschool, 15 W. 455 79th Street, Burr Ridge, IL 60527. The check should be made payable to St. Mark Christian Montessori Preschool. The September payment is due on June 15th.

Type of program: Half-day (AM/PM) Full day 3-day (circle days) M Tu W Th Fr

Child’s Name:

(First) (Middle) (Last)

Nickname: Male Female

Date of birth:

Home address:Home phone #:

(Street)

(City & State) (Zip)

Parents’ marital status:

Father’s Name:

(First) (Middle) (Last)

Home address:Home phone #:

(Street)

(City & State) (Zip)

Profession:

Work address:Work phone #:

(Street)

(City & State) (Zip)

Cellular phone #:Email address:

Mother’s Name:

(First) (Middle) (Last)

Home address:Home phone #:

(Street)

(City & State) (Zip)

Profession:

Work address:Work phone #:

(Street)

(City & State) (Zip)

Cellular phone #:Email address:

Siblings:

Name: Age:Name: Age:

Name: Age:Name: Age:

Has the child attended school before? Yes No

If so, where and when

Has the child a specific physical or emotional problem? Yes No

If so, please explain

Does the child have any allergies? Yes No

If so, please specify

Child’s Physician:

Name:Office phone #::

Office address:

(Street)

(City & State) (Zip)

Does the child receive treatment or medication regularly? Yes No

If so, please specify

Emergency contact (in case neither parent can be reached):

1) Name:Phone #::

Address:Relation to Child:

(Street)

(City & State) (Zip)

2) Name:Phone #::

Address:Relation to Child:

(Street)

(City & State) (Zip)

People other than parents/guardian authorized to pick up child: (Emergency contact from above)

1) Name:Phone #

Address:Relation to Child:

(Street)

(City & State) (Zip)

2) Name:Phone #

Address:Relation to Child:

(Street)

(City & State) (Zip)

Signature of Parent or Guardian: Date:

For Office Use Only:

Admission Date: Discharge Date:

Emergency and Consent Forms

I give permission for my child to receive emergency medical treatment. I understand that the school will provide medical treatment regardless of my religious beliefs. This may include, but is not limited to first aid, care by physician, paramedic or local hospital. I understand that I will cover any cost incurred in emergency care.

Signature of Parent or Guardian: Date:

I give permission for my child to participate in field trips off the premise of the school. I understand that my child will be transported by a professional bus driver. I understand that there will be nominal fees to be announced in advance, to cover the cost of the field trip.

Signature of Parent or Guardian: Date:

I give permission for my child to have his/her picture taken..

Signature of Parent or Guardian: Date:

I give permission for my child to receive Christian education

Signature of Parent or Guardian: Date:

Getting to Know Your Child

We would like you to help us get to know your child better since he/she is very important to us. The information below along with continuous interaction will help our staff to give exceptional care to your child while he/she is with us.

Child’s Name:

Favorite play materials

Favorite activity

Special interests

Pets

What opportunities does your child have to play with children the same age?

Does your child like to:

Cut with scissors? No  Yes Play with play-dough? No  Yes 

Be read to? No Yes Ride tricycle? No  Yes 

Play with blocks? No Yes Other

Eating habits:

Is child allergic to any food?No  Yes 

If so, please specify

Are there any foods your child does not like?No  Yes 

If so, please specify

Are there any difficulties with eating?No  Yes 

If so, please explain

Sleeping habits:

Child’s usual bedtimeWake up time

Does your child nap?No  Yes When? For how long?

Does your child tire easily? No  Yes How does he/she show this?

What does your child sleep with? (blanket, teddy bear, etc.)

Dressing:

Does your child need help with?

Pants shirt or dresssocksshoes

Coats mittensbootshats

Developmental History:

Age began speaking in words Age began speaking in sentences

Any Speech difficulties Right-handedLeft-handed 

St. Mark Christian Montessori Preschool – Child Enrollment FormPage 1 of 5