$100.00 APPLICATION FEE

AGE OF STUDENT AS OF 8-31-09__________                           SEX OF STUDENT     M _____   F _____

IS THERE A SIBLING THAT CURRENTLY ATTENDS OUR SCHOOL?     Y _____   N _____

IF YES, PLEASE LIST THEIR NAMES: _________________________________________________________________

ARE YOU INTERESTED IN 12:30 pick-up ________ 4:30 pick-up __________ OR 6:00 pick-up __________

12:30 pick-up Rate:    $2,600.00 per year upfront or $100 Registration Fee and 10 payments of $250.00

4:30 pick-up Rate:  $4,600.00 per year upfront or $100 Registration Fee and 10 payments of $450.00

6:30 pick-up Rate:  $5,100.00 per year upfront or $100 Registration Fee and 10 payments of $500.00

*If you choose to pay the years tuition by September 5^th you will receive a $100.00 discount.

STUDENT INFORMATION

NAME                                                                                                     PREFERRED NAME_____________________

                 LAST                                      FIRST                      MIDDLE

MAILING ADDRESS                                                                                                                                                                        

                                                STREET/APARTMENT NUMBER

                                                CITY                                                                       STATE                                    ZIP         

PHYSICAL ADDRESS (IF DIFFERENT FROM MAILING ADDRESS)

                                                STREET/APARTMENT NUMBER

                                                CITY                                                                       STATE                                    ZIP

LIST MEDICAL CONDITIONS/ALLERGIES                                                                                                                              

LANGUAGE SPOKEN                                                                HOME PHONE #                                                                       

STUDENT’S SSN                                                                         DATE OF BIRTH                                                                      

STUDENT RACE            AFRICAN AMERICAN ______     ASIAN______           CAUCASIAN ______

                                                NATIVE AMERICAN ______       LATINO _____          OTHER ______

PREVIOUS SCHOOL EXPERIENCE: ____________________________________________________________                                                                              

Has your child ever been tested for any of the following:

____ Speech/Language screening          ____ Hearing Screening                        ____ Other Health Impairments

PARENT/GUARDIAN INFORMATION

STUDENT LIVES WITH (CHECK ONE)           BOTH PARENTS ______       MOTHER ______      FATHER ______

                                                                                OTHER ______   RELATION TO STUDENT                                               

NAME                                                                                                                                                                                                   

                  LAST                                                     FIRST                                                      MIDDLE

PLACE OF EMPLOYMENT                                                                                                                                                             

PHONE NUMBERS            WORK                                                                                   PAGER                                                  

                                        CELLULAR                                                                                 

NAME                                                                                                                                                                                                   

                  LAST                                                     FIRST                                                      MIDDLE

PLACE OF EMPLOYMENT                                                                                                                                                             

PHONE NUMBERS            WORK                                                                                   PAGER                                                  

                                        CELLULAR                                                                  

EMAIL ADDRESS                                                                                                                                                                             

Please provide any additional information about your child that you think may assist us in his/her education:

 ________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________ 

Washington Montessori Day School does not discriminate against applicants on the basis of race, color, religion,

national origin, sex, or disabilities.  The applicant must be age 3 on or before August 31^st of the school year applied

for, and be potty trained.