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Fredericton Montessori Academy

Child Profile

Step 1 of 2

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CHILD / FAMILY INFORMATION
Name of Student*
First Last
Gender*
Gender
- Male
- Female
Date of Birth (mm/dd/yyyy)*
Medicare #*
Exp. Date*
Name of Family Physician
Telephone
Does the child has any allergies?*
- Yes
- No
If so, Please list your child’s allergies*
Parent/Guardian #1
Parent/Guardian #1 Name*
First Last
Relationship to the child*
Marital Status
Home address*
Street Address City State / Province / Region ZIP / Postal Code Country
Home Phone*
Cell Phone*
e-mail*
Place of Work*
Work Phone*
Does the child have a second parent?*
Yes
No
Parent/Guardian #2
Parent/Guardian #2 Name*
First Last
Relationship to the child*
Marital Status*
Home address*
Same as parent #1

Street Address City State / Province / Region ZIP / Postal Code Country
Home Phone*
Cell Phone*
e-mail*
Place of Work*
Work Phone*
Name of siblings and age
Name Age

Click ⊕ sign to add more
With whom has the child lived for most of the past year?*
Who will typically be picking up your child from school?*
Who does NOT have permission to pick up your child from the center?*
EMERGENCY CONTACTS (Not including parents/guardians)
Contact #1*
Name Address Phone Relationship
Contact #2*
Name Address Phone Relationship
Has your child attended public school before and if so, where?*
If yes, please attach a recent report card

Drop files here or
CHILD CARE HISTORY
Please indicate if your child has or has had any of the following:
Medical History
Measles*
Yes
No
Rubella*
Yes
No
Mumps*
Yes
No
Chicken Pox*
Yes
No
Meningitis*
Yes
No
Pertussis (Whooping Cough)*
Yes
No
Health Status
Asthma*
Yes
No
Diabetes*
Yes
No
Eczema / Psoriasis*
Yes
No
Epilepsy / Seizures*
Yes
No
Other:
Medical Treatment: Please indicate medical treatment your child may require.
Does your child need daily medication while at school?*
Yes
No
Medical Treatment*
Medication Dosage Instructions
Emergency Treatment: Please indicate any situations where emergency treatment and / or medication (s) may be required by your child (ie: Epipen, puffers/inhalers, Benedryl)
Does your child need emergency treatment while at school?*
Yes
No
Emergency Treatment*
Medication Dosage Instructions
CHILD DEVELOPMENT
Are there any hints / suggestions you could share with us to make your child’s transition to the school a positive one?*
What are your child’s interests?*
Are you aware of any learning differences your child may have or do you have any concerns about your child development?*
Yes
No
Please explain*
Is there anything else you would like to share with us about your child?

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FORM OF CONSENT
Please check the box beside the statement.*
If at any time, due to circumstances such as an injury or sudden illness, medical treatment is necessary, I (we) authorize the operator/administrator/staff of FREDERICTON MONTESSORI ACADEMY, to take whatever emergency measures are necessary for the protection of (our) my child while in their care.
Please check the box beside the statement.*
I understand this may involve applying first aid, calling a physician or nurse, carrying out the instructions given and/or transporting my (our) child to a hospital, including the possible use of an emergency vehicle.
Please check the box beside the statement.*
I understand that this may be necessary prior to contacting me (us) and that any expenses incurred for such treatment, including emergency transportation is my (our) responsibility.
ADMINSTRATION OF MEDICATION RECORD – Acetaminophen
Please check the box beside the statement.*
This authorizes staff of FREDERICTON MONTESSORI ACADEMY to administer acetaminophen to my child providing the procedures outlines below have been taken.
At the first appearance of symptoms (ie: fever), proceed as follows (to be completed by the parent):
1. Take and record the child’s temperature and symptoms on the Potential Illness form.

2. Contact the parents to discuss the symptoms and the child’s temperature and to receive the parent’s oral consent for the administering acetaminophen. Be sure to have the parent confirm with you the dosage to be administered.

3. Administer the medication in accordance with the parent’s directions and record on the Administration of Medication form.

4. Ensure that the parent signs the appropriate space on the Administration of Medication form upon their arrival at the school to confirm that he/she was consulted and agrees with the dosage given.
1. Take and record the child’s temperature and symptoms on the Potential Illness form. 2. Contact the parents to discuss the symptoms and the child’s temperature and to receive the parent’s oral consent for the administering acetaminophen. Be sure to have the parent confirm with you the dosage to be administered. 3. Administer the medication in accordance with the parent’s directions and record on the Administration of Medication form. 4. Ensure that the parent signs the appropriate space on the Administration of Medication form upon their arrival at the school to confirm that he/she was consulted and agrees with the dosage given.
CONSENT FOR OUTINGS, EXCURSIONS, ACTIVITIES OFF THE PREMISES OF THE DAY CARE FACILITY
Please check the box beside the statement.*
I give permission to Fredericton Montessori Academy (FMA) to take my child on outings, excursions and activities away from the facility, either on foot or in a vehicle providing the driver and said vehicle are properly insured for the carrying of children. I (we) understand that I (we) will receive advance notice of each planned outing, excursion, or activity away from the premises.
PHOTO PERMISSION
Please check the box beside the statement.
I hereby give Fredericton Montessori Academy (FMA) permission to use any still and/or moving image, such as video footage, photographs and / or frames and / or audio footage, depicting my/our child named above.
I hereby give Fredericton Montessori Academy (FMA) permission to use any still and/or moving image, such as video footage, photographs and / or frames and / or audio footage, depicting my/our child named above.*
Yes
No
These images may be used in the following ways (please check beside the uses you are comfortable with):*
In the building or playground of FMA
Used for advertising purposes for FMA
On the website/newsletter
Social media such as Facebook
Agreement with Fredericton Montessori Academy
Please check the box beside the statement.*
I have read the Parent Handbook and agree to its content. I agree to pay the amount noted in Annex A of the handbook.
Click here to read Parent Handbook
Parent Signature*
Parent Signature
Date*
Date Format: MM slash DD slash YYYY

Date
Date Format: MM slash DD slash YYYY

Please upload your child’s immunization form here as a document or an image, or drop it off the school office before their first day

Drop files here or

We require your child’s immunization forms before they begin the first day of school
APPLICATION FEE
We require a $150 application fee that is payable by cheque or e-transfer.

Cheque: please make payable to Fredericton Montessori Academy and drop off to the office or mail to: Fredericton Montessori Academy

711B Woodstock Road

Fredericton, NB E3B 5N8

E-transfer: please send to laura@fmacademy.ca (password: academy)
APPLICATION FEE
Price: $150.00

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