STUDENT SCHOOL APPLICATION

Child's Name:
Gender:
Date of Birth: (example: 07 14 2001)
Application Type:
Ethnic Origin: Other:
Child's Home Address:
Zip Code:
Child Resides With:
If other please explain:
Name of Guardian:
Relationship:
Home Address:
Zip Code:
Home Telephone : ( )
Cell/Alternate
Phone number:		 ( )
Employer:
Work Telephone:
If Guardian is
Attending School;
Name of School:



School Schedule:
Name of 2nd Guardian:
Relationship:
Home Address:
Zip Code:
Home Telephone : ( )
Cell/Alternate
Phone number:		 ( )
Employer:
Work Telephone:
If Guardian is
Attending School;
Name of School:



School Schedule:
Does Child Have A Sibling Currently Attending MLK? YES    NO
Have Any Other childeren In Your Immediate Family Attended MLK? YES    NO

Have You Ever Been
on any Programs(s) to Help Subsidize your child Care Costs?

CCDF/CANI    CCDF/Title X
Other (please explain)
Does Your Child
Need Bus Service 		YES    NO
Has Your Child Been Diagnosed by an Outside Source(s) as Having Special Needs?

(Please Check All That Apply)











If You Have Answered "Yes" To Any Category, Please List All Medications, Including The Name And Telephone Number
Of Your Child's Physician:
Please List Medications(s):
Physician Name:
Physician Telephone:
Physician's Place Of Employment:

I understand that this agency does not discriminate against any applicant for admission to ths school in regard to sex, race, color, religion, ethnic origin, ancestry or physical disability.
  • I understand that all the information that I have provided on this application is true and factual to the best of my knowledge.
  • I will notify the main office immediately to update any change of information that has been provided on this form and to provide current contact information in case of an emergency.
Your Name:
Email Address
Todays Date: (example: 10 24 2005)
Relationship to Child:

 

4615 Werling Drive • Fort Wayne, IN 46806
Phone: 260.423.4333 • Fax: 260.426.2366

Copyright 2008 Martin Luther King Montessori School