Summer 2018 Registration Forms

* Required Fields

Student's Name:*

First Middle Last

Student's Preferred Name:

Your Email Address*

Where you would like to receive confirmation that this form was successfully submitted.

CARPOOL TAGS

The School typically provides two (2) car pool tags per family household. Please indicate here how many total carpool tags are needed for your family:

*

CAR POOL PERMISSION

This information will be kept on file at school as a reference for any staff member involved in dismissing your child. Please inform the School Office promptly of any change. If someone other than a regular driver is to transport your child, authorization must be sent to the school via a written note delivered in the morning or phone call before 2:45 p.m. Children will be released to authorized persons only.

Persons authorized to pick up my child:

You can add additional authorized drivers by clicking the "+" sign.

Name :	Phone Number :

PUBLICITY WAIVER

I hereby authorize White Rock Montessori and representatives of WRM to utilize likenesses, photographs, recordings, or artwork of (or by) my child in any medium now known or later conceived including, but not limited to, school newsletter, Thursday Update announcements, school brochure, print or electronic media, and the WRM website. I acknowledge that my child may be identified in such photographs or recordings.

*

GENERAL WAIVER and FIELD TRIP PERMISSION

Your child will only be allowed to participate in extra-curricular activities once this section is complete.

*

I desire my child to go on any and all trips, and to participate in any and all activities, along with other students from White Rock Montessori School during his/her enrollment in the current school year. My child is now under my control and in my custody. In consideration of such child being permitted to make such trips and to take part in such activities and the instruction such child will receive by reason thereof, I hereby release White Rock Montessori School, its president, directors, teachers, and employees, together with any volunteer carrier of such child without compensation, from any and all liability and responsibility in connection with such trips and activities, and hereby release all of said parties from all liability by reason of accident or injury suffered by said child while on said trips or engaged in such activities.
No, I do not authorize this.

EMERGENCY CONTACT INFORMATION

Who the school should contact first in case of emergency. This could be the parent/guardian(s) and/or other caretakers including grandparent(s) or nannies.

First Emergency Contact's Name*

First person to contact in case of emergency.

First Last

First Emergency Contact’s Emergency Phone Number:*

Second Emergency Contact's Name

Second person to contact in case of emergency.

First Last

Second Emergency Contact’s Emergency Phone Number:

Friend or Relative to contact in case of emergency:*

First Last

Friend or Relative's Primary Phone Number:*

Friend or Relative's Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

MEDICAL INFORMATION

Has this child been hospitalized, or had a serious illness, in the past twelve (12) months? If so, please explain.*

Insurance Provider:*

Insurance Plan Number:*

Child’s Doctor :

Child's Doctor's Phone Number:

Child's Doctor's Address:

Street Address Address Line 2 City State ZIP Code

Child’s Dentist's Name:

Child's Dentist's Phone Number:

Please check items for which the school may administer without situational approval by parent/guardian.

If you have administered medication prior to the school day, alert the office in writing when additional doses may be given.

*

T-SHIRT ORDER

If you would like a WRM t-shirt, indicate what size and type shirt you would like below, and you will automatically be taken to PayPal after submitting this form to pay for your shirt(s).

Youth XS T-Shirt

Price: $10.00 Quantity:

Youth S T-Shirt

Price: $10.00 Quantity:

Youth M T-Shirt

Price: $10.00 Quantity:

Youth L T-Shirt

Price: $10.00 Quantity:

Youth XL T-Shirt

Price: $10.00 Quantity:

Adult XS T-Shirt

Price: $10.00 Quantity:

Adult S T-Shirt

Price: $10.00 Quantity:

Adult M T-Shirt

Price: $10.00 Quantity:

Adult L T-Shirt

Price: $10.00 Quantity:

Adult XL T-Shirt

Price: $10.00 Quantity:

Total

$0.00

PARENT HANDBOOK

The Parent Handbook can be found on the homepage of www.whiterockmontessori.org or by clicking here.

*

I have access to and have familiarized myself with the rules, policies, and procedures in the Parent Handbook.

SCHOOL DIRECTORY

Our School Directory is also going digital and will include the below items. This will allow increased accuracy and real-time updating, give you the capacity to copy/paste emails rather than typing them out, and access them anywhere you have an internet connection. Our directory is for our school community only and will not be shared publicly (website, Facebook, etc.).

Please check off next to items that you wish to be included in the School Directory:*

If any of this contact information has changed since enrollment/re-enrollment, please update it here:

DEMOGRAPHIC INFORMATION

WRM is committed to creating a diverse school community. Please help us in these efforts by completing the following information.

I identify my child's ethnicity as:*

Asian
Black/African
Caucasian
Hispanic/Latin
Native American
Pacific Islander
Prefer Not to Answer
Other

If "Other", please list here:

Please tell us which applies to your household:*

Choose one.

I/we are working and/or single parents who typically rely on after school care.
I/we are working and/or single parents who have a nanny and/or relative who picks up our child after school.
I/we are a family with one childcare-dedicated parent who picks up our child after school.

ELECTRONIC SIGNATURE

Electronic Signature:*

Please type your First and Last Name

I warrant the truthfulness of the information provided in this form.*

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above terms.

Summer 2018 Registration Forms – Due August 1st

Summer 2018 Online Form

* Required Fields

CARPOOL TAGS

CAR POOL PERMISSION

PUBLICITY WAIVER

GENERAL WAIVER and FIELD TRIP PERMISSION

EMERGENCY CONTACT INFORMATION

MEDICAL INFORMATION

Please check items for which the school may administer without situational approval by parent/guardian.

T-SHIRT ORDER

PARENT HANDBOOK

SCHOOL DIRECTORY

DEMOGRAPHIC INFORMATION

ELECTRONIC SIGNATURE