Child's Name: __________________  Birth Date: ___________  Age: _____ Sex: _____

Address: __________________________________________________________________

City: ______________________________ State: _________________ Zip: _____________

Father's Name: ________________ Home Phone: __________ Work Phone:___________
(or Guardian's Name)

Address: __________________________________________________________________

City: __________________________ State: _____________________ Zip: _____________

Mother's Name: _______________ Home Phone: __________ Work Phone: ___________

Address: __________________________________________________________________

City: __________________________ State: _____________________ Zip: _____________

Program Applying for: (circle one)           Montessori Class                   Extended Class

Preferred Enrollment Date:  ____________________________________________________

Other Schools Attended             Location               Grade or Level              Dates             Tel No.       

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

A non-refundable application fee of (please inquire about current fee) must accompany each application.  Please make your check payable to Pang C. Gentry and return to: Montessori Creative Learning Center, 
P.O. Box 1734, Duluth, GA, 30096. Tel: 770-232-7338

Signature of
Parent(s)
or Guardian: ___________________   ____________________Date Signed:____________