Application Form

Child’s Name:

Child’s Birth date:

Sex:

Race:

Home address:

Home Phone:

Cell Phone

Preferred?

Father’s Name:

Dad’s Birth date

ID Number:

Address if different from child’s

Employer:

Occupation :

Work Phone:

Cellphone :

Email:

Mother’s Name:

Mum’s Birth Date

ID Number:

Address if different from child’s

Employer:

Occupation :

Work Phone:

Cellphone :

Email:

Child lives with:

If Guardian:

Cellphone:

Marital Status:

If divorced, special arrangements:

Name:

Age

Name:

Age

Name:

Age

Name:

Age

Name:

Age

Name:

Age

Name (Other than Guardian)

Relationship

Phone #

Phone

Name (Other than Guardian)

Relationship

Phone #

Phone

Doctor’s name

Phone #

Medical aid name:

Member’s name

Member’s Employer:

Membership #

Suffix

Does your child have any fears, habits, experiences about which you would like us to know?

What should we know that might affect your child’s physical or emotional well-being such as illness, accident, hearing loss, allergies, diet restrictions, etc.

Does your child have any special needs?

Is English the primary language spoken at home?

If no, what is the primary language?

How did you hear about us?

Date of Registration:

1. Is the child friendly or hostile towards strangers/ peers/ siblings?

2. Does the child have tantrums?

3. Does the child take instructions well? Yes/No

4. Does the child share toys/equipment well with others? Yes/No

5. Does the child work well in a group/alone? Yes/No

6. Does the child respond well to being corrected or guided? Yes/ No

1. Is the child on Medication? Yes/ No

2. If Yes for above, give name of medication and side effects if any

3. Was the child delivered

4. Were there any complications during child birth? Yes/ No?

5. Were there any abnormalities diagnosed after birth? Yes/ No?

6. If yes, elaborate

7. Were the child’s developmental milestones normal/ delayed?

8. Did the child undergo any operations? Yes/No

9. After the operation, were there major changes physically or mentally?

Application Form

Application Form

Harare Montessori

Tarlington Preschool

Lomagundi Preschool

Marondera Preschool