Child's First Name:
Child's Last Name:
Child's Date of Birth:
Who else lives in the family home?
What is their relationship to the child?
Has there been any changes in the family dynamic within the last year?
YESNO: Are you planning a long-term trip in the next 12 months that would require your child to be out of school for more than a week at a time?
If YES, what dates will you be gone?
Please answer as honestly and completely as possible.
YESNO Has your child had or been scheduled for an IEP (Individualized Educational Plan)?
YESNO Do you have concerns about your child regarding speech, behavior or language?
YESNO Does your child receive services from the State Agency or School District?
YESNO Has your physician referred your child to an Occupational, Behavior or Speech Therapist?
YESNO If yes, may we contact professional regarding services?
If your family is already working with a therapist and/or classroom shadow, please provide the plan developed for your child.
Children with mild physical, mental or educational difficulties are considered for admission when special care or attention is not required. Reasonable accommodations will be made provided that no changes to the program are required and that the child does not pose a risk to himself or others.
A recent diagnostic assessment by qualified professionals which identifies the child’s needs within a mainstream environment is required. Periodic assessment may also be required during the school year and prior to re-enrollment. An educational assessment made during this time will determine If our environment and services supports the developmental needs of your child.
Please list any developmental concerns you may have that we need to know about in these areas:
Language (expressive or receptive):
YESNO According to the pediatrician, is your child typically developing within normal limits?
YESNO Has your child been in therapy for any particular reason?
YESNO Does your child have all the required vaccinations as mandated by the state of CA for their age group?
If you selected NO on the previous question, please answer the following:
Which immunizations is your child missing?
Why has your child not yet received these vaccines?
DifficultEasy goingSlow to warm up: How would you define your child’s temperament? (Choose one)
How would you describe your child socially with adults and other children?
What is your philosophy in respect to discipline with your child at home?
Tell us issues in this area of discipline you would like to discuss with us:
YESNO Is your child toilet independent at home?
YESNO Is your child an independent eater at home?
YESNO Does your child clean up after themselves (toys, after eating) independently at home?
What languages is your child exposed to?
What is the primary language spoken at home?
YESNO Is your child eating regular meals with the family?
How independent is s/he at home doing chores such as brushing teeth, changing clothes, brushing hair?
YESNO Does your child participate with household chores such as laundry, clean up, wiping spills, etc?
If yes, please describe:
How long and often does your child have “screen time” (TV, IPad, Tablets, etc) weekly:
When in the day does your child have “screen time”:
How long and often do you read to/with your child weekly:
At what age did your child start Montessori school?
What do you like about Montessori?
What questions do you have about Montessori?
YESNO Are you aware the Montessori method is a 3-year program (including Kindergarten)?
YESNO If not, would you like to learn more?
What are your goals for your child in the Primary Community?
What are some questions/concerns/feelings that you may have about your child entering the primary community?
YESNO Does your child have any special medications; dietary restrictions or allergies we should be aware of?
If yes, please comment:
How did you hear about us? GoogleYelpReferralOther
If Other, please describe:
If Referral, please let us know who referred you:
Which schools/day care has your child previously attended?:
I certify that my answers are true and complete to the best of my knowledge.
If this application leads to enrollment of my child, I understand that false or misleading information in my application or interview may result in the withdrawal of my child.
Signature (please type full name):