Inclusive Montessori School Registration Inclusive Montessori School RegistrationChild's InformationChild's Full Name* First Name Middle Name Last Name Preferred Name*Gender*MaleFemaleDate of Birth* Date Format: MM slash DD slash YYYY Language spoken at home*Address* Street Address City State / Province / Region ZIP / Postal Code ProgramSelect the duration and days (minimum 3) your child will attend Full day: 8:30 am - 3:30 pm Morning: 8:30 am - 11:30 am Afternoon: 12:00 pm - 3:00 pmDuration*Full dayMorningAfternoonDays* Monday Tuesday Wednesday Thursday Friday Extended care*Select any extended care options and days for your child Before care: 6:30 am - 8:30 amAfter care: 3:30 pm - 7:00 pm Before care After care NA Extended care days* Monday Tuesday Wednesday Thursday Friday It is very important to pick your child on time. Please do not be late. In case of an emergency, please contact us as early as possible. The late pick-up fee will be charged per minute. To enroll your child in our Summer Fun While Learning program, select the summer year and summer days your child will attend. Summer2023202420252026Summer Days Monday Tuesday Wednesday Thursday Friday Parent or legal guardianParent's Full Name* Dr.MissMr.Mrs.Ms.Prof.Rev. Title First name Last name Relationship to child*Address* Street Address City State / Province / Region ZIP / Postal Code Child custody*YesNoType*HomeCellWorkOtherPrimary telephone*Parent Email* Second telephoneTypeHomeCellWorkOtherThird telephoneTypeHomeCellWorkOtherCell phone carrierCell phone carrier: Select your cell phone carrier from the list to enable us to inform you of schedule changes and other events via text message. Messages will be sent to the first cell phone listed.AlltelAT&TBoost MobileConsumer CellularCricket WirelessGoogle FiMetro PCSSprintT-MobileU.S. CellularVerizonVirgin MobileRepublic WirelessOtherEmployer*Employer address*Parents marital status*MarriedSingleDivorcedSeparatedCustody and visitation: If separated or divorced, please explain the visitation arrangements for your child. If there has been a custody decision, please list the names of person NOT PERMITTED to pick up your child from school.Custody and visitation*Marital Status*Custody agreement* Currently being disputed in court Custody order issued by a court Custody established in separation agreement N/A Upload copy of any custody orders or divorce decree*Please provide Inclusive Montessori School with a copy of any custody orders or divorce decree issued by a court, or your legally binding separation agreement that establishes custody over the child. In order to maintain a safe and secure environment within the center, all custody disputed must be addressed outside the center. Thank you for your cooperation in this matter. Drop files here or Second parent or legal guardianState licensing regulations require that all appropriate fields in this section be completed in full if your child has a surviving second parent or legal guardian. Parent's Full Name Dr.MissMr.Mrs.Ms.Prof.Rev. Title First name Last name Relationship to childAddress Street Address City State / Province / Region ZIP / Postal Code Child custodyYesNoTypeHomeCellWorkOtherPrimary telephoneParent Email Second telephoneTypeHomeCellWorkOtherThird telephoneTypeHomeCellWorkOtherCell phone carrierCell phone carrier: Select your cell phone carrier from the list to enable us to inform you of schedule changes and other events via text message. Messages will be sent to the first cell phone listed.AlltelAT&TBoost MobileConsumer CellularCricket WirelessGoogle FiMetro PCSSprintT-MobileU.S. CellularVerizonVirgin MobileRepublic WirelessEmployerEmployer addressAuthorizationsImage authorization:* Yes, I authorize the use of photographs and videos of my child for the purposes listed. No child's name will be included with the images. Center marketing material Center website Center Facebook page Skin product authorization:* Yes, I authorize application of non-prescription over-the-counter (OTC) skin products to my child. Parents must provide the products in the original container, labeled with the child's name. Skin products will be applied according to the manufacturer's instructions and will not used beyond the expiration date of the product. Diaper ointment Diaper wipes Sunscreen Lip balm Other OtherNature walk authorization:* Yes, I authorize my child's participation in nature walks in the neighborhood of the center. Water play authorization:* Yes, I authorize my child's participation in water play activities during summer months. Release for pickup authorizationPlease list below, in preferential order, anyone other than the parent who has authorization to pick up your child in the case of a medical emergency, or in the event that neither parents can be reached.Check the box beside the statement: I hereby authorize Inclusive Montessori School to release my child to the following persons (other than parents). These individuals may be contacted to pick-up in case of emergency. Please note that any person other than listed below, must have a signed consent by the parents as well as bring a photo ID at the time they pick the child. A copy of the photo ID will be kept in the child’s file for future uses. Authorized pickup name*Relationship to child*Telephone*TelephoneAuthorized pickup nameRelationship to childTelephoneTelephoneAuthorized pickup nameRelationship to childTelephoneTelephoneAuthorized pickup nameRelationship to childTelephoneTelephoneSpecial instructionsEmergency medical contactsPhysician name*Physician telephone*Physician address*Physician nameDentist telephoneDentist addressEmergency medical authorization: I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, in the event that such an emergency occurs and I cannot be reached, I hereby authorize Inclusive Montessori School to transport my child to the hospital listed below and to secure for my child all necessary medical treatment. I understand that the staff at Inclusive Montessori School is trained in the basics of first aid, and I authorize them to provide my child with first aid when appropriate. Hospital name*Hospital telephone*Hospital address*Medical information Health forms: The State of New Jersey requires each child enrolled in an early childhood program to have a Universal Health Record and Immunization Record on file at the program. (Click here to download). Each child enrolled in an early childhood program must have had a physical examination performed by a health care provider, within:i. Six months prior to admission, for children who are 2½ years of age or younger; orii. One year prior to admission, for children above 2½ years of age The Hamilton Township Health Department requires that all children receive a flu vaccination by December 31. Parents must provide proof of vaccination to the school. Please submit the health record and immunization record before your child's first day. Your child may not begin school without it. Enter the dates of the most recent physical examination and most recent flu (influenza) vaccination. Physical examination Date Format: MM slash DD slash YYYY Flu Date Format: MM slash DD slash YYYY Immunization exemption: All children are required to receive immunization vaccines unless they have a state approved exemption. If your child is exempt from state immunization requirements, provide us with the applicable exemption form and check exempt below. If your child is exempt from receiving varicella vaccine because he/she has had the varicella (chicken pox) disease, check exempt below.ImmunizationRequiredExemptVaricella vaccineRequiredExemptImmunization:For each vaccine listed below, enter the number of doses your child has received to date as indicated on the child's record of immunization.Hepatitis B0123DTaP012345IPV01234PCV01234Hib01234Rotavirus0123Hepatitis A012MMR012Varicella012HPV012Tdap012MCV012Medical insuranceMy child is covered by the medical insurance policy listed below. I accept responsibility for all medical expenses incurred by the child care provider on behalf of my child. If your child requires accommodations for daily activities, special equipment, or medical supplies, a Care Plan for Children With Special Health Needs (click here to download) must be completed by the child's physician and submitted to the office.Insurance carriePolicy numberGroup numberName of policy holderAbout your child Complete the following as appropriate for your child. If none enter none. Thank you for sharing this helpful information with us so we can better understand the individuality of your child. Health concernsList any concerns about your child’s general health (eating, sleeping habits, posture, teeth, skin, weight, bowel/bladder, etc.)Vision problemslist any vision problems your child has (difficulty seeing, crossed eyes, frequently reddened or watery eye)Child wears Eyeglasses Contact lenses Hearing aids N/A Hearing problemslist any hearing problems your child has (frequent earaches, difficulty hearing, etc.)Speech problemslist any speech problems your child has (difficulty having speech understood, stammering, delayed speech development, etc.)AllergiesMedical conditionslist any any specific illnesses, disabilities or limiting conditionsEvaluation and care Received evaluation which could help us meet health or educational needs Requires special health care while at Inclusive Montessori N/A Dietary restrictionsI request that my child not eat the following foods while at Inclusive Montessori School. Please list the food and the reason.Personal historyParents who live outside householdPet names and typesPrevious group care experienceActivities you do with childThings child does wellChild struggles withSpecial interestsDislikesClasses child is enrolled inAge began sittingAge began crawlingAge began walkingAge began talkingGood climberYesNoFalls easilyYesNoSpeaks Words Sentences Has difficulty speaking N/A Special wordsSpecial words to describe child's need or commonly used words that the teacher can use to communicate with the child if their primary language is other than English.Eating habitsNormal meal timesFavorite foodsFoods refusedFood allergiesEating problemsEating utensilsToilet habitsToilet training Not started Started Accomplished Easy Difficult Toilet training explanationExplain if toilet training was difficult or reason if not accomplishedReliable indications: Can child be relied upon to indicate bathroom needs?YesNoUrination and bowel movement wordsToilet assistance requiredToilet fearsToilet frequencyNormal for ageMore frequent than normalLess frequent than normalWets bedNoYesfrequencySleeping habitsBed timeWake timeNap timeSleeps in Own room Own bed Crib None of these Takes to bedMood on wakingDuring sleepIf child walks, talks, or cries during sleep please describe.Social relationshipsExperience playing with other childrenHow child gets along with siblingsPrefers same age playmatesYesNoChildren child knows at our schoolHow child relates to unfamiliar adultsDemands a lot of adult attentionYesNoMakes child upset or angryHow child shows feelingsBest way to comfort childHome discipline methodsPhysical activities child enjoysFrightens child Animals Unfamiliar adults Other children Loud noises The dark Storms Insects/bees Other OtherChild enjoys Animals Unfamiliar adults Other children Loud noises The dark Storms Insects/bees Other OtherActivities experienced Riding a tricycle Using scissors Finger painting Water play Cooking Gardening Riding a Bus Other OtherActivities experienced Active Shy/quiet Outgoing Sensitive Intense Persistent Adaptable Content CommentsPersonality and abilitiesHow can we helpIn what ways can we help your child with activities that cause difficulty?Helpful equipment or routinesOther household membersNameRelationshipDate of birth Date Format: MM slash DD slash YYYY NameRelationshipDate of birth Date Format: MM slash DD slash YYYY NameRelationshipDate of birth Date Format: MM slash DD slash YYYY NameRelationshipDate of birth Date Format: MM slash DD slash YYYY HolidaysInclusive Montessori will be closed for the following holidays: Labor Day (September)Thanksgiving (November) Christmas Eve (December)Christmas Day (December) New Year’s Eve - half day (December) New Year’s Day (January)Birthday of Martin Luther King, Jr. (January)President’s Day (February) Good Friday (March/April)Easter (March/April)Memorial Day (May)Independence Day (July)Enrollment agreementLate pick up fee: $5 for one minute For school enrollment Enrollment fee + Montessori Membership fee $300 (one time payment & non refundable) One time supplies fee is $100 (one time payment & non refundable) All time tuition is non refundable in all situationsTuition Policy: Inclusive Montessori has a 10-month academic year for all classes. The academic year begins in September and ends in June of the next year. Tuition is are based on the full year’s fee, which has been divided into 10 equal monthly payments for your convenience. Upon enrollment, the first payment must include the first and last month’s tuition. Tuition is payable only by online payment or ACH bank account transfer. Payment for each month is due by the 29th of the preceding month. A late fee will be assessed for each day tuition is not paid beginning on the first day of the month. Tuition will not be refunded or pro-rated due to absences caused by illness, vacations, withdrawals, dismissals, or otherwise. Tuition must be paid even for a full month vacation. Deposit is non-refundable in the form of cash. Deposit will applied to pay for services provided by the school for the last month. Schedules may be changed in September with 15 days advance notice. Schedules may not be changed for the remainder of the academic year. Notify the school in April if your child will or will not be attending the summer program. Discount: For those who pay full when you enroll, Inclusive Montessori offers a 10% discount for your tuition. There is also a 10% discount for siblings enrolling in the month of August and September. Your registration fee will be discounted if you enroll in August or September. If a child enrolls in the school with your reference, you will receive a gift certificate if they enroll in the full-time program or the part-time program. Extended Care Fee: If you desire your child to stay during a class period that they are not enrolled, the parent must ask permission from the teacher prior to the class beginning. If your child is permitted to attend the class, the extended charge will be per hour. You will be billed all the additional expenses from the extended care. Late Pick-up fee: Inclusive Montessori is open from 6:30 am – 7:00 pm. From the time that your child is scheduled to be picked up, each additional minute late will be billed per minute. Disclosure: Parents are required to report in writing to Inclusive Montessori, any physical, mental, or emotional disabilities of the child. Any other matter which could affect the child’s enrollment and/or participation at the school must be reported as well. This included all illnesses, allergies, or medications. Withdrawal: Parents may terminate this agreement with a 30-day notice. Your deposit will be applied to your last month’s tuition. Without a written notice and withdrawal of your child, your deposit will not be refunded in the form of cash. Failure to Pay: Inclusive Montessori will reach out to legal agencies for the collection of unpaid tuition 30 days after the tuition is due. In the event that it becomes necessary for Inclusive Montessori to employ a collection agency and/or attorney for unpaid tuition, the parents agree to pay all expenses incurred by Inclusive Montessori, whether or not the litigation is initiated. Expenses will include, but are not limited to all postage fees, attorney fees, and court fees. Delinquent account will be sent to the company or lawyer contracted by Inclusive Montessori for all collection management.Parent or legal guardian signatureClick the document names to download: Information to Parents, prepared by the Bureau of Licensing in the Division of Youth and Family Services. Policy on the Release of Children Guidelines for Positive Discipline Policy on Methods of Parental Notification Policy on the Management of Communicable Diseases Policy on the Use of Technology and Social Media Medication Administration Policy and Procedures Expulsion Policy Behavior Management Policy Parent HandbookI have received and read Information to Parents Policy on the Release of Children Guidelines for Positive Discipline Policy on Methods of Parental Notification Policy on the Management of Communicable Diseases Policy on the Use of Technology and Social Media Medication Administration Policy and Procedures Expulsion Policy Behavior Management Policy Parent Handbook Check the box beside the statement: I have read the full Enrollment Agreement and fully understand the policies, curriculum, and terms of tuition responsibilities of Inclusive Montessori. Upon signing, I agree to abide by the policies both financial and otherwise, as stated in the handbook and this form. I certify that the information I have provided is accurate to the best of my knowledge. I agree to udate this form immediately if any information changes. I certify that my electronic signature entered below is legally binding. Electronic signatureDate Date Format: MM slash DD slash YYYY ONE TIME BANK (ACH) PAYMENT AUTHORIZATIONCheck the box beside the statement:* By signing this form, you give us permission to make a one (1) time debit from your checking or savings account for the amount indicated on or after the indicated date_ This is permission for a single transaction only, and does not provide authorization for any additional unrelated debits or credits to your account. I authorize Inclusive Montessori School to charge my bank account indicated below for $*I authorize Inclusive Montessori School to charge my bank account indicated below on*This payment is for the following:*Billing InformationBilling Address* Street Address City State / Province / Region ZIP / Postal Code Phone#*Email*Bank DetailsAccount Type:*SavingsCheckingAccount Name*Bank Name*Account Number #*Routing Number #*Check the box beside the statement:* I understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted transaction date. In the event the payment is rejected for Non-Sufficient Funds (NSF), I understand that the Merchant may, at its discretion, attempt to process the charge again within thirty (30) days. I agree to an additional $ charge for each attempt returned NSF, which will be initiated as a separate transaction from the authorized payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I will not dispute the Merchant so long as the transaction corresponds to the terms indicated in this agreement. Account Holder Signature*Date* Date Format: MM slash DD slash YYYY The child’s placement is not secured until all applicable sections of this form have been completed and the enrollment fee has been returned to the office Inclusive Montessori School admits students of any race, color, national and ethnic origin to all rights, privileges, programs and activities generally made available to students at the school. Inclusive Montessori School does not discriminate on the basis of race, color, national or ethnic origin in the administration of its educational and admission policies or school administered programs.
