1 2018/19 School Year Registration

1.0 2018/19 School Year Registration

Sept. 2018- June 2019

2018/19 School Year Registration Form
When you submit the form it will redirect to the Paypal payment screen where you can make payment online with a credit card. No Paypal account is required.
$125. Non-Refundable Registration Fee*
Campus*
- Bloomfield
- Clifton
Start Date
Date Format: MM slash DD slash YYYY
Age
Student Name*
First Last
Gender*
- Female
- Male
Student Birth date*
Date Format: MM slash DD slash YYYY
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Parent/Guardian #1
Parent 1 Name*
First Last
Parent 1 Gender*
- Female
- Male
Parent 1 Cell Phone*
Parent 1 Email*
Parent 1 Occupation
Parent 1 Place of Employment
Parent 1 Work address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Parent 1 Work/Alternate Phone Number*
Parent/Guardian #2
Parent 2 Name
First Last
Parent 2 Gender
- Female
- Male
Parent 2 Cell Phone Number
Parent 2 Email
Parent 2 Occupation
Parent 2 Place of Employment
Parent 2 Work address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Parent 2 Work/Alternate Phone Number
Child's living arrangements*
- Both Parents
- Mother Only
- Father Only
Child's Legal Guardian*
- Both Parents
- Mother
- Father
Previous Schools
School Reason for Leaving Contact Name Phone

List names of school/s previously attended if any, reason for leaving, and contact name and number.
Anytime Pickup/Emergency Contacts
Name Relationship Phone

Please list at least two people, OTHER THAN YOURSELVES, that have your permission to pick up your child/children at any time without prior notification from the parent/guardians. Anyone coming to pick up your child/children MUST have proper Identification (ex. Drivers License) on them or your child/children will not be released.
How did you hear of our school?
- Referral
- Clifton Merchant
- Google Search
- Drive By
Who can we thank for their referral?
First Last
Name of Doctor/Practice
Doctor phone number*
Allergies/Dietary/Medical Restrictions
Allergy Dietary Restrictions Medical Conditions

Does your child have any allergies to food and/or medicine, dietary/religious food restrictions, medical conditions such as Asthma etc., existing illness, health concerns/limitations that we should be aware of? If yes, please explain and send in proper documentation.
Medication Administration Release
- Epi-pen
- Nebulizer
Does your child use any of the following? If Yes, please print the appropriate action plan from below, have your Dr. fill them out and return them prior to your child starting school. Please Note: If your child requires an Epi-pen you and your Dr. must fill out the Rainbow Montessori Epi-pen release form and the Food, Allergy, Anaphylaxis Emergency Care Plan forms.

Rainbow Montessori Epi-pen release form

Food, Allergy, Anaphylaxis Emergency Care Plan

Asthma Action Plan
Must be completed by a Physician. Please Note: Universal Child Health Records must be updated every school year. Please make sure they are turned in prior to the start of school.
Drop files here or
Universal Child Health Record
Parental/Guardian Agreement
Parental/Guardian Agreement
Should your child suffer an injury or illness while in the care of Rainbow Montessori School and the facility is unable to contact me/us or our Emergency Contact/s immediately, it shall be authorized to secure such medical attention and care for the child as may be necessary. I/we shall assume responsibility for payment for services and release Rainbow Montessori School, it's staff etc. from any and all liabilities from acting on my/our behalf.

Before any medication is dispensed to my/our child, I/we will provide written authorization from his/her Physician and myself, which includes: Date, Child's Name, Name of Medicine, Prescription Number, Dosage to be given, Date and time of day medication is to be given. Medicine will be in the original container with my/our child's full name clearly marked on it.

My child will not be allowed to enter or leave the facility without being escorted by the parent(s), a person authorized by the parent(s), or faculty personnel. You must drop off and pick up your child/children from their classroom door.

I acknowledge it is my responsibility to keep my child's records current to reflect any significant changes as they occur, e.g., telephone numbers, work location, emergency contacts, child's physician, child's health status, infant feeding plans and immunization records, etc.

The facility agrees to keep me informed of any incidents, including illnesses, injuries, adverse reactions to medications, etc., which include our/my child.

Rainbow Montessori agrees to obtain written authorization from me before our/my child participates in routine transportation, field trips, special activities away from the facility, and water-related activities occurring in water that is more than two (2) feet deep.

I/We understand that it is my/our responsibility to read the digital copy of The Parent Handbook which explains our procedures and policies. I have read and understood all of the policies and procedures as outlined in the attached: Parent Handbook 2018-19 Parent Handbook 2018-19 School Year

I/We understand that the facility will advise me of our/my child's progress and issues relating to our/my child's care as well as any individual practices concerning our/my child's needs.

I/we understand that if our/my child will be out for an extended period of time (more than 2 weeks) I/we are responsible to pay half of my/our monthly tuition to hold my/our child's spot. If our/my child will be out for (less than 2 weeks), then I/we understand there will be No discount given.

I/we understand that Rainbow Montessori School requires thirty (30) days written notice of early withdrawal from our/my Parental Agreement. I/we will be responsible to pay one (1) months tuition for the month following our/my child's last day at Rainbow Montessori School.

I/we understand that if my/our account falls two (2) payments behind, I/we will be asked to remove our/my child from the program and my/our account will be sent into collections.

I/we understand that we are required to participate in four (4) MANDATORY Fundraisers throughout the school year which will be noted on the 218/19 School Year Calendar.

I/we are required to sell/purchase a minimum of $50 Per Fundraiser/Per Child or I/we have the right to pay the "opt-out" fee of $50. per child/per fundraiser which is due at the time the current fundraiser ends. In addition to the above mentioned I understand that I am also required to purchase/sell 2 tricky tray tickets when tickets go on sale. https://rainbowmontessori.hubbli.com/fundraising-contract-50/

DO NOT FILL THIS FORM OUT UNLESS YOU HAVE BEEN DIRECTED TO DO SO......For Families receiving 4c's/ Programs for Parents/scholarship: I/we are required to sell/purchase a minimum of $100 Per Fundraiser/Per Child or I/we have the right to pay the "opt-out" fee of $100. per child/per fundraiser which is due at the time the current fundraiser ends. In addition to the above mentioned I understand that I am also required to purchase/sell 4 tricky tray tickets per child when tickets go on sale. https://rainbowmontessori.hubbli.com/fundraising-contract-100-4cs-discounted-and-or-scholarship-tuition/

I/we give Rainbow Montessori permission to take the children out for walks during the nice weather, or for the purpose of an emergency evacuation.

I/we hereby authorize the release of pertinent medical information (medical conditions, allergies, and/or medication regimes) to be exchanged among appropriate professional staff involved in the care of the above student. This consent is valid for the entire time the student is enrolled in our school and is intended to allow the staff to better serve my child

I have read and understood the attached Expulsion Policy https://rainbowmontessori.hubbli.com/expulsion-policy/

I have read the attached Information to Parents form: https://rainbowmontessori.hubbli.com/information-to-parents/

I have read and understood the attached Parent Code Of Conduct policy https://rainbowmontessori.hubbli.com/parent-code-of-conduct/

I have read and understood the attached Terms and Conditions of Tuition Payments policy: https://rainbowmontessori.hubbli.com/terms-and-conditions-of-tuition-payments/

I have read and understood the attached the Amendment Approval Letter: https://rainbowmontessori.hubbli.com/amendment-approval-letter/
Agreement/Policy/Procedure Confirmation*
- By checking this box and signing this form I/we are confirming that I/we have read and fully understand the policies and procedures that are required of me/us to keep my/our childe/children enrolled in Rainbow Montessori School.
Parent/Guardian #1*
Date*
Date Format: MM slash DD slash YYYY
Parent/Guardian #2
Date
Date Format: MM slash DD slash YYYY
TEST FIELD
Total
$0.00

Hubbliville Academy

1 2018/19 School Year Registration

1.0 2018/19 School Year Registration

2018/19 School Year Registration Form

Parent/Guardian #1

Parent/Guardian #2

Parental/Guardian Agreement

Parental/Guardian Agreement

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School	Reason for Leaving	Contact Name	Phone

Name	Relationship	Phone

Allergy	Dietary Restrictions	Medical Conditions