Medina Montessori | Enrollment Form

Student name*

Gender*

Male

Female

Program Seeking to enroll*

Schedule*

Toddler Half Day (8AM-12:15PM)

Toddler Standard Day (8AM-2:15PM)

Toddler Full Day (8AM-5:30PM)

Primary Half Day (8AM-12:15PM)

Primary Standard Day (8AM-2:15PM)

Primary Full Day (8AM-5:30PM)

Elementary Standard Day (8AM-3PM)

Elementary Full Day (8AM-530PM)

Any Allergies? *

Father's Name*

Mother's Name *

Physician Name

Does your child have health insurance? *

Yes

Payment Authorization

I authorize Medina Montessori to charge my $295 annual materials fee once this form is received as well as monthly tuition on the 1st of each month. I understand that any change in billing or cancellation requires 30 days notice

Payment Method

Will provide new payment info

Use account on file