Date:  _________________




                                                  
  MIDLAND MONTESSORI SCHOOL
  2010-2011

Registration Fees:  $175 for all programs

All registration fees are non-refundable
Sorry, No Exceptions



Child's Name:  _____________________________  Nick Name: ____________


Date of Birth:  ___________  Male/Female      Program:  _____________________  

Home Address:  _________________________________ Zip:  ____________

Home Phone:  _____________________  E-Mail Address:  ________________ 

Father's Name:  ______________________  Social Security Number:  _____________

Home Address (if different): ___________________________________________

Work Phone:  _________________________     Cell Phone:  _____________________

Occupation: _____________________     Place of Employment: ___________________

   Are you willing to be contacted for occupation associated advice?  ____ Yes  ____ No

Mother's Name:  _______________________  Social Security Number: ____________

Work Phone:  _________________________    Cell Phone:  _____________________

Occupation: _____________________     Place of Employment: ___________________

   Are you willing to be contacted for occupation associated advice?  ____ Yes  ____ No

Referred By:  ________________________________

Reduced tuition opportunities are available. Families in financial need should contact
the Director for more information.