<p>   #21-19490 Fraser Way, Pitt Meadows, BC V3Y 0B6 Phone: 604-460-8558 Montessori Preschool Email: [email protected]</p><p>KinderHeart Montessori Daycare Registration Form Office use only (Start date: ______End date______)</p><p>Name of Child______Name preferred______</p><p>Date of Birth ______/______/______Male / Female (please circle) (dd) (mm) (yyyy)</p><p>Preferred Starting Date: Month______Year______</p><p>Age at starting date:_ Years______Months______</p><p>Home Address: ______</p><p>______</p><p>Home Phone______Email______</p><p>Primary Care Giver’s Name: ______</p><p>Day Phone______Cell______Preferred# to call during day______</p><p>Place of Employment: ______</p><p>2nd Guardian’s Name: ______</p><p>Day Phone______Cell______Preferred# to call during day______</p><p>Place of Employment: ______</p><p>Language spoken in home ______Language concerns______</p><p>If yes, please explain______</p><p>Previous preschool/daycare experience Yes/No (please circle)(Answer A&B if answered yes)</p><p>(A) If yes, where and how long______</p><p>(B) Why are you transferring to KinderHeart______</p><p>______Daycare (please check daycare program required)</p><p>2-day Program (7:30-5:30pm) ______drop - off time ______pick - up time ______</p><p>3-day Program (7:30-5:30pm) ______drop - off time ______pick - up time ______</p><p>4-day Program (7:30-5:30pm) ______drop - off time ______pick - up time ______</p><p>5-day Program (7:30-5:30pm) ______drop - off time ______pick - up time ______</p><p>Pricing for 2, 3, 4 and 5 daycare programs</p><p>2-day program $495.00 / month 3-day program: $595.00 / month 4 day program: $650.00 / month 5-day program: $750.00 / month (Children under 36 months – full-time fee: $850.00 / month except I/T Care).</p><p>Other If your child will not be in KinderHeart’s 2, 3, 4 or 5-day programs, please specify below the care required (part-time spots may not always be available):</p><p>______</p><p>Price / Month as agreed upon between parent(s) and KinderHeart: ______</p><p>Drop In Daycare Rates Half day - $40.00 (up to 4 hours) Full day - $60.00 (4 or more hours)</p><p>How did you hear about KinderHeart Montessori? Local paper: _____Friend _____ Flyer: _____Internet _____Web site_____ other: ______I am enclosing a non-refundable $75.00 registration fee ($25 for returning children) with this application form. I understand that the tuition is refundable upon one month’s written notice of withdrawal up to March 1st and that there will be no refunds issued for any portion of the tuition after March 1st. It is also my understanding that the school reserves the right to accept or refuse any application and that the registration fee will be refunded if the school is unable to provide my child with a space.</p><p>Signature: ______</p><p>Printed Name: ______Date: ______</p>