Preferred Dates (4 weeks minimum) *

6/24 - 6/28

7/1 - 7/5

7/8 - 7/12

7/15 - 7/19

7/22 - 7/26

7/29 - 8/2

8/5 - 8/9

8/12 - 8/16

Afterschool Care

Afterschool Care is calculated at $500/week.

Yes

No

Afterschool Care Weeks

6/24 - 6/28

7/1 - 7/5

7/8 - 7/12

7/15 - 7/19

7/22 - 7/26

7/29 - 8/2

8/5 - 8/9

8/12 - 8/16

Child's Name *

First Name

Last Name

Child's Birth Date *

MM

DD

YYYY

Child's Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone *

(###)

###

####

Name of Parent/Legal Guardian 1 *

First Name

Last Name

Cell Phone *

(###)

###

####

Name of Parent/ Legal Guardian 2

First Name

Last Name

Cell Phone

(###)

###

####

Who is financial responsible for child's tuition? *

First Name

Last Name

Billing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is your child taking any medication? *

Yes

No

Parent/Legal Guardian Signature *

I hereby apply for admission of my child, named above, to Ms. Lam Montessori for the Summer Program.

First Name

Last Name

Date *

MM

DD

YYYY