Static Form

MONTESSORI AT THE OLD SCHOOLHOUSE

2018 SUMMER PROGRAM APPLICATION FORM

Please [print_button], fill it out, and bring it in with your check or send to:
MONTESSORI AT THE OLD SCHOOLHOUSE
557 West Kerley Corners Road, Tivoli, NY 12583

Child’s Name: ________________________________
Birth Date: ________________________________
Nickname: ________________________________
Gender: Female     Male
Address: ____________________________________________________
Parent 1: _______________________ Parent 2: _______________________
Relationship: _______________________ Relationship: _______________________
Phone: _______________________ Phone: _______________________
Email: _______________________ Email: _______________________
Emergency Contact: ____________________________________
Phone: ____________________________________
Allergies: ____________________________________
Anything else? ____________________________________


On the below table, please circle all fees that apply to you for the specific times your child will be attending, add up the totals from each row to get your weekly total, then add the last column to get your grand total for the summer and enter it in the “Tuition” box. Unfortunately, due to our space limitations, you cannot set your own schedule beyond the set days below (e.g. you could not choose Mon-Tue-Wed-Thu as your 4-day schedule one week). Please pay this total by including a check payable to Montessori at the Old Schoolhouse along with this form.

5 Days
mon-fri		 4 Days
mo-tu-th-fr		 3 Days
mo-tu-wed		 3 Days
wed-th-fri		 In
Diapers		 Totals
June 18-22
(off Mon)		 $115 $105 $95 $95 $15
June 25-29 $115 $105 $95 $95 $15
Jul 2-6 (off Wed) $115 $105 $95 $95 $15
July 9-13 $115 $105 $95 $95 $15
July 16-20 $115 $105 $95 $95 $15
All 5 Weeks
(discounted!)		 $550 $505 $455 $455 $70
Total:

I, the undersigned, agree to pay my child’s tuition for the ______ (year) Summer Program at Montessori at the Old Schoolhouse in full before the summer session begins, and understand that this fee is non-refundable.

Signature: ______________________________
Date: ______________________________

Montessori at the Old Schoolhouse does not discriminate based on race, religion, sex, color, creed, national or ethnic origin.

Please [print_button], fill it out, and bring it in with your check or send to:

MONTESSORI AT THE OLD SCHOOLHOUSE
557 West Kerley Corners Road, Tivoli, NY 12583
Josephine & Anna Salvatico • jstivoli@aol.com • 845-758-3434