You are on page 1of 1

Registration Application

Date of Registration: _____

Student’s Information: Name: First Middle Last __________________________________


Date of Birth: _____/______/_______ Age: ______

Health: Indicate any medical condition/behavior challenge or allergy.


____________________________________________________________________________
Parent / Guardian Information:
Mother’s Name: _________________________________
Father’s Name: ____________________________________________________________
Address: __________________________________________________________________
____________________________________________________________________________

Cell Phone: __________________________ Email: ______________________________


Cell Phone: __________________________ Email: ______________________________

Emergency contacts and persons authorized to pick up your child:


Name __________________________ Cell Phone _______________ Relationship________
Name __________________________ Cell Phone _______________ Relationship________

Note: Proof of identification will be requested when picking up your child.

I, ________________________________________________________ (parent/guardian
name) understand the program payment policy. I agree to be on time for the
tutoring/enrichment sessions. I agree to contact Success Montessori Prep (SMP) in advance if
my child cannot attend a tutoring/enrichment session. I have made SMP aware of any health
concerns, challenges, behavioral and other important issues that relate to my child’s education.
My child is currently up to date on all vaccinations as mandated by the State of NJ.
I understand that tuition is non-refundable and non-transferrable. I release all owners,
administrators, instructors or participants of any claims, actions or suits which could result from
accidents or injuries while enrolled in tutoring classes with Success Montessori Prep, LLC. I also
understand that Success Montessori Prep, LLC reserves the right to cancel this contract at any
time with a prorated refund.

I have applied for enrollment of my child with Success Montessori Prep, LLC and I have
thoroughly read the policies notice and agree to abide by the rules and policies.

Signature of Parent or Guardian:___________________________________


Date: _____________________________