Unitarian Society Montessori School 176 Tices Lane, East Brunswick , NJ 08816 (732) 246-0606 APPLICATION FOR ADMISSION (please print) Summer Camp 2009 |
| Name of Student ____________________________________________________________________________ Address ___________________________________________________________________________________ Home Phone ( )_____________________Sex________ Age________ Date of Birth ____________________ Email Address: ______________________________________ Father's Name ______________________________________ Business Phone___________________________ Business Name _______________________ Business Address______________________________________ Occupation _________________________ SS#______________________ Cell Phone______________________ Mother's Name ______________________________________ Business Phone___________________________ Business Name _______________________ Business Address______________________________________ Occupation _________________________ SS#______________________ Cell Phone______________________ Marital Status________________ Children Living With __________________ Other Children in the Family (Names and Ages) __________________________________________________ Is there any medical, environmental, or behavioral history that would be useful in helping to understand your child? ________________________________________________________________________________________ Child’s Pediatrician ________________ Phone ______________________ Address _______________________________________________ Emergency Contact ____________________Phone_________________ Please indicate desired week or weeks: July 06 _____ July 12 _____ July 19 _____ July 26 _____ Aug. 02 _____Aug. 09 _____Aug. 16 _____Aug. 23 _____ Please enter AM, PM, or FULL in the blanks below: Number of Days: 5 Days_____ 3 Days (MTW)_____ 2 Days (Th F)_____ Hours Per Day: Full Day (9-3:30)_______ Half Day AM (9-11:30)_______ Half Day PM (1-3:30pm)_______ Will you need extended hours daycare? Yes _____ No_____ If Yes, AM (7-9) _____ PM ( 3:30-6:30 ) _____ Signature__________________________________________________________________Date___________ |