Please , fill it out and bring it in or mail it.


557 West Kerley Corners Road, Tivoli, NY 12583


Child’s Name: ________________________________
Birth Date: ________________________________
Nickname: ________________________________
Gender: Female     Male
Address: ____________________________________________________
Phone: ________________________________
Birthplace: ________________________________
Allergies: ________________________________
Is child adopted? Yes   No    If yes, does the child know? _______________


Parent 1: _______________________ Parent 2: _______________________
Relationship: _______________________ Relationship: _______________________
Phone: _______________________ Phone: _______________________
Email: _______________________ Email: _______________________
Occupation: _______________________ Occupation: _______________________
Hours: _______________________ Hours: _______________________

With whom does child reside? _________________________

Who is financially responsible for the child’s tuition? _________________________

Emergency Contact: ____________________________________
Phone: ____________________________________


Are there any other adults living with child? ____________________________

Any pets at home? _______________________


Name Date of Birth Gender


Previous school/ childcare situation:

Reason for leaving:

How did you learn about Montessori at the Old Schoolhouse?

What made you choose a Montessori program?

What do you expect to receive from a Montessori Program?


Is your child toilet trained? Yes     No
What words are used for bathrooming? ____________________________________
When did your child start to walk? ____________________________________
Did she/he crawl? ____________________________________

Please list your child’s strengths, interests and talents?

Please describe your child’s personality and temperament?

Please check any that apply to your child:

◻ Shyness◻ Fearfulness◻ Thumb sucking / Pacifier / Bottle

◻ Easily upset ◻ Shyness ◻ Other:

Please feel free to share any additional information you would like us to know about your child or your family (e.g. any areas needing special attention, goals for your child at school, etc):

Has your child had any serious illness, operations, or accidents (including any complications at birth, allergies, etc)? If yes, please specify?

Has your child had any recent changes (e.g. change in residence, new baby, family illness or death of a loved one or pet)?


Please rank your choice of program (1st, 2nd, and 3rd):
____ 5 days a week *
____ 4 days a week (Monday, Tuesday, Thursday, Friday)
____ 3 days a week (Monday, Tuesday, Wednesday)
____ 3 days a week (Wednesday, Thursday, Friday)

Please note: No substitutions of days without prior approval
* Kindergarten children must attend five days a week

Primary Tuition:
5 days/week – $4100.00 ($410.00 / 10 installments)
4 days/week – $3700.00 ($370.00 / 10 installments)
3 days/ week – $ 3170.00 ($317.00 / 10 installments)

Toddler Tuition (or any child still in diapers in primary classroom):
5 days / week – $ 4510.00 ($451.00 / 10 installments)
4 days / week – $ 4050.00 ($405.00 / 10 installments)
3 days / week – $ 3520.00 ($ 352.00 / 10 installments)

Thank you for taking the time to fill out this application as completely as possible. The information contained in it will be kept confidential. Please return this form with a nonrefundable application fee of $50.00. We must receive both the completed form and the fee before your child can be considered for placement in our program. If we are able to offer your child a place at Montessori at the Old Schoolhouse, we will contact you to begin the enrollment process.

Signature: ______________________________
Date: ______________________________

Montessori at the Old Schoolhouse does not discriminate based on race, religion, sex, color, creed, national or ethnic origin.

Please , fill it out and bring it or mail it.