MONTESSORI AT THE OLD SCHOOLHOUSE
557 West Kerley Corners Road, Tivoli, NY 12583
TODDLER APPLICATION FORM
| Child’s Name: | ________________________________ |
| Birth Date: | ________________________________ |
| Nickname: | ________________________________ |
| Gender: | Female Male |
| Address: | ____________________________________________________ |
| Phone: | ________________________________ |
| Birthplace: | ________________________________ |
| Allergies: | ________________________________ |
| Is child adopted? | Yes No | If yes, does the child know? | _______________ |
PARENTS / GUARDIANS
| 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: | ____________________________________ |
FAMILY LIFE
Are there any other adults living with child? ____________________________
Any pets at home? _______________________
Siblings:
| Name | Date of Birth | Gender |
SCHOOLING / CHILDCARE
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?
________________________________________________________________
CHILD BACKGROUND
| Did your child crawl? | _______________________________ |
| When did your child start to crawl? | _______________________________ |
| What words does your child use for food? | _______________________________ |
| Other words that would be helpful to know about? | _______________________________ |
Please list your child’s strengths, interests and talents?
________________________________________________________________
Please describe your child’s personality and temperament?
________________________________________________________________
How do you calm your child down when she/he is upset?
________________________________________________________________
Please check any that apply to your child:
◻ Shyness◻ Fearfulness◻ Thumb sucking / Pacifier / Bottle
| ◻ Easily upset | ◻ Shyness | ◻ Tantrums | ◻ 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)?
________________________________________________________________
PROGRAMS & TUITION
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
Toddler Tuition:
5 days / week – $ 4550.00 ($455.00 / 10 installments)
4 days / week – $ 4150.00 ($415.00 / 10 installments)
3 days / week – $ 3600.00 ($360.00 / 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.