Genesis Montessori Gifted Academy

Ad Donatum, et Verum – To the Gifted and the True

Student Information Form

Student Password

Name

First Name

Last Name

D.O.B

Gender

Ethnicity

Home Address

City

State

Zip

Preferred Phone

Parent/Guardian Name

Contact #

From

Part-time

Full-time

Family Information

Child Lives With

Custody

Mother

Father

Both

Other

Mother Information

Mother’s Name

Address

Home Phone

Employer

Work Phone

Cell

Father Information

Father’s Name

Address

Home Phone

Employer

Work Phone

Cell

Other

Specify

Can I text you?

Yes

Medical Information: I hereby grant Genesis Montessori Gifted Academy full permission to contact the following medical personnel to obtain emergency medical care if warranted.

Doctor

Address

Phone Number

Dentist

Address

Phone Number

Hospital of Choice

Please list allergies, special medical dietary needs, or other areas of concerns

Emergency Care Plan Instructions (if applicable)

Emergency Contacts: Child will be released only to the custodial parent or legal guardian and the persons listed below. The following individuals will also be contacted and are authorized to remove the child from the facility in case of illness, accident or emergency, if for some reason, the custodial parent or legal guardian cannot be reached:

Name

Address

Work Phone

Home Phone

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GMGA Notice of Non-Discriminatory Policy

Genesis Montessori Gifted Academy, Inc. does not discriminate against any student or staff on the basis of race, color, national or ethnic origin, in admission or participation in its programs, GMGA does not discriminate and offers equitable service to students and staff without prejudice as it relates to administration of educational policies, admissions policies, scholarships, GMGA clubs or any other school-related or school-sponsored programs.