Early Learner Enrollment Application Child’s Full Name:__________________________________________________ Nick Name:_______________________________________________________ Date of Birth:______________________ Gender: M/F Desired Program: __Early Learner 5 days 8:45-12:00 __Early Learner 5 days 8:45-3:00 __Early Learner 5 days 8:45-4:00 __Early Learner 5 days 8:45-5:30 __Early Learner 3 days 8:45-12:00 __Early Learner 3 days 8:45-3:00 __Early Learner 3 days 8:45-4:00 __Early Learner 3 days 8:45-5:30 __Early Learner 2 days 8:45-12:00 __Early Learner 2 days 8:45-3:00 __Early Learner 2 days 8:45-4:00 __Early Learner 2 days 8:45-5:30 Desired Start Date:_____________________ Family Information List ALL Members of Child’s Household: Name Age Relationship ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Parent’s Marital Status: (circle one) Married Divorced Separated Single Parent Other If Divorced or Separated, what are your child’s living arrangements? What about custody arrangements? ________________________________________________________________ ________________________________________________________________ How often does your family see extended family? (circle one) Daily Weekly Monthly Annually Page 1 of 4 What methods of discipline are implemented at home? Please describe below: ________________________________________________________________ ________________________________________________________________ Does your family/child speak any other languages? Y/ N If Yes, What Languages? _______________________________________________________________ Does your child enjoy playing outdoors? Y / N Does your child engage in fantasy play? Y / N If Yes, Please Describe: ________________________________________________________________ ________________________________________________________________ How many hours weekly does your child watch TV? ______________ Please list child’s favorite shows: ______________________________________ How many hours weekly does your child use technology (Computers, Tablets, Smart Phones, etc.)? __________________ Please List what activities your child enjoys and on which type of technology? ________________________________________________________________ ________________________________________________________________ Childcare Information Describe any previous school experiences or group situations: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ If you had previous experiences, do you feel these experiences were generally good? Y/ N If No, Please Explain: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Did your child have any difficulties at any other schools or group situations (behavioral, academic, social or emotional)? Y / N If Yes, Please Describe: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Does your child prefer to play/work alone or with other children? ________________________________________________________________ Page 2 of 4 When with other children, how does your child react to conflict? ________________________________________________________________ Does your child take regular naps? Y / N For how long: _______________ Please Describe his/her naptime routine: ________________________________________________________________ ________________________________________________________________ Has your child had any Montessori experience? Y / N Are you familiar with the Montessori Philosophy? Y / N If Yes, Please Describe: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Are you aware that the next level of your child’s education is the Primary Montessori Program and is based on a 3 year cycle? Y / N Health and Development Does your child have allergies? Y / N If Yes, Please Describe: ________________________________________________________________ ________________________________________________________________ Does your child have any dietary restrictions? Y / N If Yes, Please Describe: ________________________________________________________________ ________________________________________________________________ Does your child have any difficulty with: (circle all that apply) Speech Vision Hearing Emotions Physical Development Eating Health Problems If you circled any of the above, Please describe: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Page 3 of 4 What skills has your child acquired? __Knows ABC’s __Walking __Interested in potty training __Knows Words(circle one) 0 – 50 50-100 100-150 150-200 __Climbs On To Low Items __Feeds Self __Stacks Items __Remembers Familiar Songs/Books __Walks up the Stairs __Kicks a Ball __Count to…how far?_____ __ Follows Simple Instructions __Potty training… (circle one) Fully Trained Working on it __ Runs Steadily __Catch Self With Hands if Falling __Holds/Draws with Crayon __Explores Cause and Effect __Express Needs..how?(explain below) ________________________________ __Throws Ball Miscellaneous How did you learn about Blue Ridge Montessori School?(choose one) Friend: Name___________ Advertisement Other:___________ Is there any other information that might help our staff better understand your child? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ What are your goals for your child/family for this upcoming school year? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Page 4 of 4
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