* Required Fields

Student's Name*

First Name	Last Name	Preferred Name

CAR LINE TAGS

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

You will receive a car line number at the beginning of the school year and it is critical that number be visible from your front windshield throughout the car line pick up process. If you lose your car line tag, or need additional copies for alternate pick up, please contact the front office at office@whiterockmontessori.org.

CAR LINE CHANGE NOTIFICATIONS

Students will be released to their parent or guardian or to those authorized for routine (i.e. every Wednesday) pick up here on this form or on the Car Pool Permission form.

To authorize any other individuals to pick up your child, the school must receive communication from the parent/guardian by 2:30 p.m. (10:45 a.m. for Primary morning car line). In order to ensure the safety of all children on campus, changes are not able to be made to your student’s pick up plan after 2:30 p.m. (10:45 a.m. for Primary morning car line).

The school may require identification before releasing the child to anyone other than the child’s parent.

Please check the 2019 Parent Handbook for complete car pool guidelines.

Car Pool Routine Schedule

Please use this form for any adult other than the student's parents to pick up the student on a routine basis. You can add additional authorized drivers by clicking the "+" sign.

Student's First Name(s)	Will be picked up by __ (Adult's Name)	On these days (for example, every Wednesday)	Their phone # is

SCHOOL PHOTOS

Individual Portrait and Class Photos taken by Robin Jackson Photography:*

School Photos will take place during the week of September 16-20, 2019.

Yes - I want my child(ren) to be photographed on their school portraits day and I authorize their inclusion in school pictures during the 2019-2020 school year. I grant permission to Robin Jackson Photography, as a representative of White Rock Montessori (WRM), to take photographs and/or digital images of my child. These photographs will become available to me and I also understand they may be used in publications of WRM such as, but not limited to, the WRM Yearbook and lunch cards. I understand that Robin Jackson Photography will retain the copyrights to all photographs and acknowledge that student portraits will be accessible for viewing and purchase within a single, password protected, gallery.*
No - I do not authorize this.

PUBLICITY WAIVER

Photos taken by WRM faculty and staff:*

Yes - I 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 Montessori Compass, 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.
No - I do not authorize this.

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.

STUDENT INTERNET USAGE POLICY

Do you have a student who will be in either Upper Elementary (grades 4-6) or Middle School (grades 7-8) at WRM next year?*

Yes
No

Please review the Internet Usage section of the Parent Handbook to familiarize yourself with WRM's policy for internet usage.

I have read and understand the Parent Handbook information about appropriate use of the internet at White Rock Montessori,

Please click the checkbox for each description. Each item must be initialed before your child will be permitted to access the internet from school.

Select All
I approve of my child’s access to the internet during classroom activities as explained in the Parent Handbook.
I understand that my child may be refused access to the internet if he or she is found to violate the rules against accessing inappropriate materials as explained by the teacher or computer instructor.
I do not hold the school responsible for misuse of the internet by my child.

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:

Person to call in case of emergency*

(if parents cannot be reached)

First Last

Person's relationship to student*

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.

*

PARENT HANDBOOK

The Parent Handbook can be found on the Parents page at 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.

PARENT PROFESSION(S)

Optional

Profession(s) held by the student's parent(s)/guardian(s)

Click the plus icon (+) to add another parent/guardian

Parent's Name	Parent's Profession	Parent's Employer

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:

BUSINESS INTERNSHIPS

During the week of December 2nd, Middle School (MS) students will participate in a one-week business internship. Students select a business about which they want to learn and arrange to spend a week working there. No payment is received by the student during this process. The supervising adult at the business completes an evaluation of the student's internship at the end of the week.

Please check below if your business would be interested in hosting a MS student for an internship.*

Yes - my business would be interested in hosting a MS student for an internship.
No or Not Applicable

Business Name

Contact Person at Business

Who the MS student should contact regarding the internship.

First Last

Contact Person's Phone Number

Contact Person's Email Address

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
Other
Prefer Not to Answer

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

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.

Electronic Signature*

First Last

Your Email Address*

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

ORDER A 2018-2019 YEARBOOK

There is still time to order your 2018-2019 yearbook!

Would you like to order a 2018-2019 yearbook?*

2018-2019 yearbooks will be delivered Fall 2019.

Yes
No
I already ordered one.

How many yearbooks would you like to order?*

Price: $30.00 Quantity:

Total

$0.00

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Credit Card Billing Address*

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

Summer 2019 Online Form – Due August 1st

Summer 2019 Online Form

* Required Fields

CAR LINE TAGS

CAR LINE CHANGE NOTIFICATIONS

Students will be released to their parent or guardian or to those authorized for routine (i.e. every Wednesday) pick up here on this form or on the Car Pool Permission form.

SCHOOL PHOTOS

PUBLICITY WAIVER

GENERAL WAIVER and FIELD TRIP PERMISSION

STUDENT INTERNET USAGE POLICY

Please review the Internet Usage section of the Parent Handbook to familiarize yourself with WRM's policy for internet usage.

EMERGENCY CONTACT INFORMATION

MEDICAL INFORMATION

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

PARENT HANDBOOK

PARENT PROFESSION(S)

SCHOOL DIRECTORY

BUSINESS INTERNSHIPS

DEMOGRAPHIC INFORMATION

ELECTRONIC SIGNATURE

ORDER A 2018-2019 YEARBOOK