Online Application I. PRIMARY INFORMATION Student’s Name: First: Middle: Last: Student's Date of Birth (mm/dd/yyyy): Gender: ---MaleFemale State or Country of Birth: Primary Language: Secondary Language? Primary Address: Street: City: Zip: II. CONTACT INFORMATION Mother/Legal Guardian: Primary Phone: Alternate: E-mail address: Occupation and Title: Employer: Work Hours: Phone: Father/Legal Guardian: Primary Phone: Alternate: E-mail address: Occupation and Title: Employer: Work Hours: Phone: Emergency Contact: Primary Phone: Alternate: III. FAMILY INFORMATION Child resides with: ---MotherFatherBoth Parents are: ---MarriedSeparatedDivorced If the parents are separated or divorced, please advise: Legal custodian: To whom should we send correspondence? Who is financially responsible for this child? Secondary Address: Street: City: Zip: Please list all siblings’ names and dates of birth: Student’s ethnicity: (Optional, but we would love to keep historical track of the diversity of our school) ---African/African AmericanAsian/Asian AmericanCaucasianLatino/HispanicMiddle EasternNative AmericanPacific IslanderMultiracial If multiracial, please specify ethnic groups: IV. Education History Current School: Phone: Address: Street: City: Zip: Please list the names and dates of previous schools your child has attended, back to age 2. Name: Dates: Name: Dates: V. ENROLLMENT COMMITMENTS Should you enroll your child in Village Montessori as of September 2013, you will be asked to read through and complete our Parent Commitment Form (available as pages 3-4 of the downloadable application). By clicking submit I assert that the information provided on this application is true and accurate to the best of my knowledge. Parent/Legal Guardian: Parent/Legal Guardian: Date(mm/dd/yyyy): NOTE: A $50 non-refundable application fee must accompany each application and can be mailed to, or dropped off at, the school's physical address.