Application Form

Lakewood Montessori Christian School - Application Form
Part A: Student Information
Student Name*
First Last
Home Address*
Street Address City State / Province / Region ZIP / Postal Code
Home Phone #*
Birth Date (MM/DD/YYYY)*
Date Format: MM slash DD slash YYYY
Religion
Doctor*
Address*
Phone#*
Special Needs (important information regarding your child):
Part B: Parent Information
Parent 1 Name*
First Last
Home Address*
Same as child's home address

Street Address City State / Province / Region ZIP / Postal Code
Employer*
Employer Address*
Home #*
Cell#*
Work#*
Work# ext
Parent Email
Parent 2 Name
First Last
Home Address
Same as child's home address

Street Address City State / Province / Region ZIP / Postal Code
Employer
Employer Address
Home #
Cell#
Work#
Work# ext
Parent Email
Part C: Emergency Contact

(List in order, names of persons to be called in an emergency situation, excluding parents)
Emergency Contact#1 Name*
First Last
Address*
Employer
Employer Address
Home #*
Cell#*
Work#*
Work# ext
Email*
Emergency Contact#2 Name*
First Last
Address*
Employer
Employer Address
Home #*
Cell#*
Work#*
Work# ext
Email*
Part D: Release Information (names of persons to whom the child may be released)
Name*
Relationship*
Contact#*
Name
Relationship
Contact#
Name
Relationship
Contact#
Check the box beside the statement:*
I will contact the School Office immediately if any of the above information changes. I certify that all this information is correct.
Signature*
Non-refundable initial fee
Price: $1,000.00
Date
Date Format: MM slash DD slash YYYY

Once you submit the application, please pay $1000 non-refundable initial fee. The initial fee can be E-transfered to carmenshave@gmail.com with the designated password LAKEWOOD

Lakewood Montessori Christian School

Lakewood Montessori Christian School - Application Form

Part A: Student Information

Part B: Parent Information

Part C: Emergency Contact

Part D: Release Information (names of persons to whom the child may be released)

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