ELITE MINDS

117 UNION STREET • BROOKLYN, NY 11231

APPLICATION FEE: $40.00
Please submit payment below or mail in with your Health Form.

CHILD
Name of Child *
Name of Child
Date of Birth *
Date of Birth
Child's Gender *
PARENT/GUARDIAN
Name *
Name
Phone Number *
Phone Number
2nd PARENT/GUARDIAN
Name
Name
Phone Number
Phone Number
CONTACT INFORMATION
Primary Mailing Address *
Primary Mailing Address
Primary Home Phone *
Primary Home Phone
Name, Age, School Attending
CAREGIVER
Caregiver *
Please indicate whether a caregiver, sitter, or nanny works with your child during the day
Caregiver's Name
Caregiver's Name
What is the nature of the caregiver's relation to the family?
Guardianship
Child's Legal Guardian *
Child's Legal Guardian
Parent/Guardian Union
What is the marital status of the primary parents/guardians?
If primary parents/guardians live separately, please indicate to what degree and how often the child transfers between adults
MEDICAL
REQUIRED Child Health Examination Form (see PDF below) *
HAVE YOU FILLED OUT AND RETURNED THE PDF BELOW? via email: enroll@elitemindsmontessori.com or post: ENROLL Elite Minds Montessori, 117 Union Street, Brooklyn, NY 11231
Please indicate any existing conditions, allergies, or health concerns your child may have
Please use this space to elaborate on your child's development, character, or any other pertinent information you would like to include
ENROLLMENT
Program *
Please select the program(s) you wish to enroll your child in.
Days *
Please check which days
Schedule *
Please check which time(s) you will be applying for.
Supplemental Programs
Please check the program options that interest you
APPLICATION FEE
40.00
Quantity:
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