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American Indian or Alaska Native A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment. Asian A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Black or African American A person having origins in any of the black racial groups of Africa. Terms such as "Haitian" or "Negro" can be used in addition to "Black or African American." Hispanic or Latino A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term, "Spanish origin," can be used in addition to "Hispanic or Latino." Native Hawaiian or Other Pacific Islander A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. White A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Other Other nationality or prefer not to say. Invalid Input
What does your child do when not in school? (Watch TV, read, play with other children, etc.)
Next > Household Information
In the past three years have there been any significant changes within the family? (death of family members, separation/divorce/remarriage, major trauma or illness, job changes)
Please explain the event(s) and the child’s reaction below
What activities does the family do together? (Watch TV, camping, hobbies, sports, etc.)
< Prev Next > Medical/developmental History
At birth, child was
List any complications which occurred during pregnancy (example diabetes, toxemia, etc.)
List any complications which your child had immediately during or after birth (ex. Emergency c-section, long labor, difficulty pushing, Difficulty breathing, blue color, etc.)
Check any problems in infancy or childhood with
Compared to other children in the family, this child’s development has been
Are there any specific developmental issues that you are concerned about?
Has your child’s Dr. mentioned any specific developmental issues that he/she is watching?
Has your child had any of the following medical conditions
< Prev Next > Behavioral Health History
Briefly describe your child’s relationship with you, your spouse, and other members of the family
Is there any history in the immediate family of mental or emotional difficulties? (Examples: depression, bipolar disorder, ADD/ADHD, Asperger’s Syndrome, etc.)
Check all items applicable to your child
Have there been any recent changes in behavior?
How do you discipline and/or motivate your child at home? (Extra chores, early bedtime, spanking, praise, etc.) What is your child’s reaction?
< Prev Next > Educational History
Where does your child attend school?
List all schools attended from preschool to present:
Location of school
Child writes with
Do you feel your child is experiencing problems learning or in school?
What kind of problems? When did it start? Describe anything you have done or tried to make it easier for your child
Child’s best subject Invalid Input and worst subject Invalid Input
Is there a history of learning difficulties in your family? (Example: slow learning, easily distracted, poor reading, etc.)
Has your child ever been tested before?
Please give date and location of testing
Has your child been diagnosed as
List the area(s) in which you feel your child needs help
Other comments regarding your child’s education or schooling
< Prev Next > Medical Consent
Permission To Treat:
In the case of an accident, injury or illness, I authorize Rooted Life Montessori (administrators, faculty, staff or designated volunteers) to seek and obtain any medical help deemed necessary for my child.
I will not hold RLM liable in the case of illness or accidental injury.
I will not hold RLM responsible for any medical fees incurred.
In the event that I cannot be reached to make arrangements for emergency medical attention for my child at the time of an accident,injury or illness, I hereby authorize Rooted Life Montessori to call 911 and have my child transported to the nearest hospital emergency room and obtain any medical help deemed necessary for my child. *Please click "yes" to agree
Does the student have any medical conditions?
Does the student have any allergies?
Please list here allergies to any medications, foods, or environmental allergies (ants, bees, chemicals, etc.)
Is the student prescribed any medications?
Do any of these medications have an effect on your child’s behavior or ability to think or attend to tasks?
Do any of these medications have difficult side-effects?
Name and explain any health/behavioral condition(s), past or present, which need to be brought to the school’s attention to safeguard this student at school (e.g. diabetes, seizures, asthma, emotional disorders, educational challenges, etc.) or which would restrict physical or academic activities
< Prev Next > Oil Usage Consent
At Rooted Life Montesssori we use essential oil defusers in our classrooms. In some cases we may also use essential oils as topical treatments for minor ailments such as sun burn, bug bites, bee stings (unless there is a known allergy), cuts, bruises, scrapes, seasonal allergies, and upset stomachs. If you wish for your child to not receive topical treatments with essential oils or only with specific oils please let our staff know below.
Do you consent for your child to be treated with essential oils for minor ailments?
Are there any oils that you do not wish used?
< Prev Next > Media Consent
Permission to Publish Images and Photo Release Policy
Rooted Life Montessori respects the privacy of our students and families first and foremost. For the purposes of promoting Rooted Life to the community, and potential enrolling families, the therapy center publishes images of our students captured while they are at work in their classrooms, on field trips, in musical productions, and during other therapy center events that provide an accurate and positive portrayal of student, parent, staff and faculty life atRLM. For that reason, it is the goal of the therapy center to gain universal permission to include images and video of (all) students in promotional materials, including but not limited to: printed collateral, website content, Facebook posts, Weekly E-newsletter, videos, print media, signage, banners, display boards and more.
Our pledge for protecting your child/our students is supported by a set of precautionary rules and policies that are designed to facilitate promotion of the therapy center without compromising the safety and welfare of our students and families:
Rules for Photographic Image Security The name of a student will never be disclosed on any advertisements, publicly distributed print materials or publicly accessible content including, but not limited to, social media, videos, therapy center website, and more without specific permission. Therapy centergenerated videos where the voice/s and images of students accompany video images will not accompany a student name.
Parents must send special request in writing if they wish for their child(s) image not be used in RLM promotional materials (see list above) to Charissa, Administrator. When permission to publish images is denied, the result is that Rooted Life will exclude that child from class photographs, and small and large group photographs that would otherwise be perfectly suited for inclusion in the chosen media distribution format.
I hereby grant to Rooted Life Montessori, their successors, and their assignees the right to record the image and/or voice and use the artwork and/ or written work of my child, on videotape, on film, on photographs, in digital media and in any other form of electronic or print medium and to edit such recording at their discretion. I understand that my child’s full name, address and biographical information will not be made public.
I further grant Rooted LIfe Montessori their successors, and their assignees the right to use, and to allow others to use, my child’s image and/or voice on the internet, in brochures, and in any other medium and hereby consent to such use.
I hereby release Rooted Life Montessori, their successors, and their assignees and any using my child’s image and/or voice, artwork, and/or written work pursuant to this media release form any and all claims, damages, liabilities, costs and expenses which I or my child now have or may hereafter have by reason of any use thereof. I understand that the provisions of this release are legally binding.
< Prev Next > Emergency Contacts and Authorized Pickup
Will your child be delivered/picked up by a Child Care Center?
Is there anyone that your child may NOT be released to?
< Prev Next > Preference Assessment
The preference assessment is for us to learn about what your child likes, or what motivates them to complete activities and tasks. Please check the boxes below that match your child's preferences and fill out the below fields.
Things to do
How does your child like to unwind and relax?
Anything else you would like to share about your child’s preferences?
< Prev Next > Discipline Release
Much work goes into preparing an environment to
prevent misbehavior. We require that children respect themselves, others and their environment. Children are given attention for appropriate and kind behavior. We use your child’s preferences to further motivate them toward appropriate behavior. Discipline means instruction. The guides are trained to observe why children are not following a rule using Applied Behavior Analysis (ABA).
RLM employs a staff RBT (Registered Behavioral Technician) to help evaluate a student’s behavior needs based on the science of ABA. The RBT(s) at RLM work under the supervision of a BCBA (Board Certified Behavior Analyst) at all times. If a child’s behavior is not normalizing with the implementation of both Montessori philosophy and/or ABA, and/or the child’s behavior becomes a threat to the safety of other children or staff, the parent will be required to provide additional services such as counseling, ABA, or other behavioral therapy. If the parent does not wish to provide additional services, the child will be removed from the program without refund of the deposit or payments. While
we work hard to ensure that every child is successful in our environment, we realize our classrooms and educational philosophy is not the right fit for every child or parent.
I understand that Discipline (training and instruction) must be:
(1) Individualized and consistent for each child;
(2) Appropriate to the child’s level of understanding; and
(3) Directed toward teaching the child acceptable behavior and self-control.
The staff at RLM may only use positive methods of discipline and guidance that encourage self-esteem, self-control, and self-direction, which include at least the following:
(1) Using praise and encouragement of good behavior instead of focusing only upon unacceptable behavior;
(2) Reminding a child of behavior expectations daily by using clear, positive statements;
(3) Redirecting behavior using positive statements; and
(4) Using brief supervised separation or time out from the group, when appropriate for the child’s age and development, which is limited to no more than one minute per year of the child’s age.
There must be no harsh, cruel, or unusual treatment of any child. The following types of discipline and guidance are prohibited:
(1) Corporal punishment or threats of corporal punishment;
(2) Punishment associated with food, naps, or toilet training;
(3) Pinching, shaking, or biting a child;
(4) Hitting a child with a hand or instrument;
(5) Putting anything in or on a child’s mouth;
(6) Humiliating, ridiculing, rejecting, or yelling at a child;
(7) Subjecting a child to harsh, abusive, or profane language;
(8) Placing a child in a locked or dark room, bathroom, or closet with the door closed; and
(9) Requiring a child to remain silent or inactive for inappropriately long periods of time for the child’s age.
My signature verifies I have read and received a copy of this discipline and guidance policy.
< Prev Next > Electronics Release
Rooted Life Montessori does NOT allow any forms of electronics on the campus for the children enrolled: iPad, tablets, phones, cameras, gaming devices, or basically anything that accepts batteries or an electrical power supply.
1st offense: the device will be taken from the child and returned at the end of the day.(Parent will receive notification of the event, but the teacher will allow the child to remedy the situation)
2nd offense: the device will be taken from the child and must be retrieved by the parent.
3rd offense: the child will be excused from class immediately to be picked up by the parent. The child will not be able to return for 7 days (a tuition refund will not be allowed).
If the parent is unable to retrieve the child, the child will be released to an authorized adult on the child’s Authorization For Releaseform.
< Prev Next > Financial Contract
Children are enrolled for the term from Aug-May. Classes are held Monday-Friday from 7:45-12:30. Tuition, Materials fees, etc will not be adjusted due to absence, illness, withdrawal or removal of the students by the parents. If parents stop sending their child to the therapy center, without giving their 2-week notice, payment is still expected. If you leave mid-contract, no payments will be returned. Enrollment deposit secures a student's enrollment for the
year. When we ask for a deposit at registration, we are asking for a commitment to plan for your child before the term begins: preparing the environment, purchasing materials, and hiring the staff begins long before the doors open in August. This deposit is non-refundable. Thank you for partnering with us in preparing for your child's individualized education. Program Options Payment Options
< Prev Next > Testing Consent
I give permission for my child,
to participate in Pre -Admission testing offered by Rooted Life Montessori Staff. I understand that I am giving permission for the staff to determine the specific tests which would reveal my child’s areas of strength or weakness to determine an individualized education or therapy plan. The fee charged for this testing will include a follow-up meeting to go over the results. I also understand that I will receive a written report indicating how my child performed on this test. I may choose at that time whether to allow my child to participate in any of the therapeutic programs that may be recommended.
< Prev Next > Equal expectations
Rooted Life Montessori Therapy Center Mission Statement to you:
RLM will provide authentic Montessori education to diverse academic learners,
nurture the whole child, support the innate desire to learn with guidance and inspiration foster self-confidence, motivation and critical thinking teach responsibility and social skills, focusing on grace and courtesy instill leadership and respect for self/others in a well-prepared environment accommodate the learning different child within their ability
We will provide:
individualized academic instruction for your child based on Montessori philosophy and curriculum individualized behavior redirection based on our observation and implementation of ABA behavior analysis 2 in person parent-teacher conferences yearly (fall and spring) a mid-term update via Montessori Compass (winter) additional referrals or recommendations if we observe academic or behavior remediation is advised a low student-teacher ratio
Participation in parent-education seminars, emails, online forums and other methods of educating you about Montessori Time spent learning about Montessori Compass and the materials your child is using. Timely payments
I have read this Statement of equal expectations and agree with the beliefs and principles therein. I support RLM in its purpose and mission as a Montessori Therapy Center and will seek to be a role model for my family and encourage my children to do likewise as long as we are enrolled at RLM.
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