Cross of Life Christian Montessori School
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Contact Us
Online Registration Form - All fields must be completed as indicated
*
Indicates required field
Academic Year
*
2016-17
2017-18
2018-19
2019-20
Emergency Contact Information
Child's name
*
First
Last
Child's Date of Birth MM/DD/YYYY
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Address
*
Line 1
Line 2
City
State
Zip Code
Country
Name of Parent/Guardian 1
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First
Last
Parent/Guardian 1 Email
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Home Phone
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Cell Phone
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Work Phone
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Employer
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Employer's Address
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Home address if different than above
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Name of Parent/Guardian 2
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Parent/Guardian 2 Email
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Home Phone
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Cell Phone
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Work Phone
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Employer
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Employer's Address
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Home address if different than above
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Emergency Contacts and Persons authorized to pick up child (other than Parent/Guardian). A phone number and address is required for each person.
1. Name
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First
Last
1. Address
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2. Name
*
2. Primary phone number
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2. Address
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3. Name
*
3. Primary phone number
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3. Address
*
Photo Permission Form
During the school year many photos and/or videos will be taken of the children while they participate in both classroom activities and special school events. These images may be used on our school website, blog, in advertising or school publications. Photos used on the web or in advertising of any nature will not list the names of the children.
Photo Permission
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Yes, my child's photos may appear in school publications and social media
No, my child's photo may not be used in school publications and social media
Medical Information Form
Allergy Information
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My child has no known allergies
My child has allergies which are detailed below
Allergies and Reactions
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I understand that anaphylactic or severe reactions requiring medication must complete the 'Emergency Action Plan' on file in the office.
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Yes
Other medical alerts
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Prescriptions taken on a daily basis
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Pediatrician's Name
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Address
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Phone Number
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Preferred Hospital
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Special Instructions
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Primary Insurance
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Name of Insured
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Policy/Group Number
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Health History
Hospitalized
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Yes
No
Reason
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Chronic Illness
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Ear Infections/Tubes
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Speech Delay or Impairment
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Other information that would be helpful for caregivers
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Medical Release
To Whom it May Concern:
I hereby authorize the bearer, who is a staff member at Cross of Life Christian Montessori School, to sign any forms required to admit my child for emergency treatment at the nearest facility. I do so in order to ensure that my child may recieve prompt medical attention in cae of emergency when I cannot reach the facility promptly.
I certify that I will be liable for all medical and hospital expenses incurred in this regard.
I certify that all information on the Medical Form is true and complete.
Electronic Signature
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By checking yes, I authorize my signature typed above
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Yes
No
Today's Date MM/DD/YYYY
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Bright From the Start/GA Department of Early Childcare and Learning and Liability Insurance
I undertand the following:
1. Cross of Life Christian Montessori School is not licensed by Bright From the Start – Georgia Department of Early Care and Learning.
2. Cross of Life Christian Montessori School carries liability insurance for the staff, board members, and enrolled students under the policy of Cross of Life Lutheran Church.
Choose One
*
Yes
No
Electronic Signature
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Submit