! MONTESSORI AT THE OLD SCHOOLHOUSE 557 West Kerley Corners Road, Tivoli, NY 12583 845-758-3434 • [email protected] Josephine & Anna Salvatico 2015 SUMMER PROGRAM APPLICATION FORM Child’s Name: ______________________________________ Birth Date: ____________ Child’s Nickname: ___________________________________ Gender: Female or Male Address: __________________________________________________________________ Parent 1: __________________________________ Relationship: ____________________ Home: _____________________________ Work Phone: ___________________________ Cell Phone: _________________________ E-mail: ________________________________ Parent 2: __________________________________ Relationship: ____________________ Home: _____________________________ Work Phone: ___________________________ Cell Phone: _________________________ E-mail: ________________________________ Emergency Contact: _________________________ Phone Number: __________________ Allergies: _________________________________________________________________ __________________________________________________________________________ Anything else we should know?: _______________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 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. (For example, if your child will be attending for 3 days the first week (Wed-Thu-Fri = $90) and 4 days the second week (Mon-Tue-Thu-Fri=$100) and all available days the week before Indepence Day (Mon-Tue-Wed-Thu-Fri=$110) and s/he is in diapers, then your tuition would be $345.) 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 the week of June 22nd). Please pay this total by including a check payable to Montessori at the Old Schoolhouse along with this form. 5 Days 4 Days 3 Days 3 Days mon-fri mo-tu-th-fr mo-tu-wed wed-th-fri In Diapers $110 tu-wed-thu-fr $100 $90 $90 $15 June 22 - 26 $110 $100 $90 $90 $15 Jun 29 -Jul 3 $110 $100 $90 $90 $15 $110 $100 $90 $90 $15 June 16-19 (off Mon) July 6 - 9 (off Fri) mon-tu-wed-th July 13 - 17 $110 $100 $90 $90 $15 All 5 Weeks (discounted!) $525 $480 $435 $435 $70 Totals Tuition 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. Parent/Guardian Signature: _________________________________ Date: ____________ Montessori at the Old Schoolhouse does not discriminate based on race, religion, sex, color, creed, national or ethnic origin.