Step 1 of 8

Program

Choose the program your child is enrolled in:

Program Selection *

Toddler Community
Primary Environment

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Allergy & Medical Emergency Release

Student

Name of Student *

Full Name

Date of Birth *

Date of Birth

Parents

Parent 1 *

Parent 1

Home

Work

Mobile *

Mobile

Parent 2

Home

Work

Mobile

Other Guardians

Other 1

Other Relationship 1

Relationship

Other Contact #1

Contact #1

Other 2

Other Relationship 2

Relationship

Other Contact #2

Contact #

Doctor

Doctor *

Full Name

Doctor Phone *

Phone

Pager

Pager #

Medical

Medical Insurance Company *

Medical Insurance Company

Medical Policy / Card *

Medical Policy / Card

Special Instructions

Known allergies:

Indications / symptoms of onset of allergic reaction:

Immediate action that can be taken upon onset of allergic reaction:

In the event that my child is ill, injured, or having a serious allergic reaction, and the Mosaic Montessori Academy (MMA) staff is unable to reach any of the parties listed on page 1 of this form, I authorize any MMA staff to take the following step(s):

Emergency Option Selection *

Take my child to a hospital and give consent for emergency treatment/care.
Call 911 and give consent for emergency treatment/care.
Call our primary physician as follows:

Parent Authorization & Date

Parent Name *

Parent Name

Date of Acknowledgment *

Parent Signature *

Clear Signature

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Parent Handbook Acknowledgement

This Parent Handbook is created to provide parents with clear guidelines and promote a thorough understanding of the policies & procedures at Mosaic Montessori Academy.

We encourage you to take the time to familiarize yourself with this handbook, as it will help foster a positive and eﬀective relationship with our school faculty and staﬀ. Team MMA looks forward to collaborating with you to build a dynamic and supportive community where students, staﬀ, and parents can all thrive together.

Please complete, sign, and return this acknowledgment form upon receiving and reading the Parent Handbook. This acknowledgment will be added to your child’s permanent file. Your signature confirms that you have thoroughly read and understand the policies and procedures outlined in the handbook.

I / we have received, read, and understand the policies and procedures outlined in the Mosaic Montessori Academy Parent Handbook.

Parent Acknowledgement & Date

Parent 1 *

Parent 1 Name

Date of Acknowledgment *

Parent 1 Signature *

Clear Signature

Parent 2

Parent 2 Name

Date of Acknowledgment

Parent 2 Signature

Clear Signature

Student

Student *

Full Name

Classroom / Program *

Classroom / Program

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Illinois State Late Pick-up Procedure

Please read thoroughly

In accordance with Illinois Regulations DCFS 407.260(f) , Mosaic Montessori Academy (MMA) maintains a Late Pick-Up procedure.

MMA is open until 6:00pm during the regular school year, as follows:

Toddler Morning 8:30am–11:45am
Toddler Extended 8:30am–3:15pm
Toddler Full Day 7:30am–6:00pm
Primary Morning 8:30am–11:45am
Primary Extended 8:30am–3:15pm
Primary Full Day 7:30am–6:00pm

Dismissal or pick-up schedules will be strictly enforced. Morning and Extended program students picked up more than ten(10) minutes after dismissal time will be assessed a Late Pick-Up Fee of $50.00 per hour or any fraction thereof. Full Day program students picked up after 6:00 PM will be assessed a Late Pick-Up Flat Fee of $50.00.

Starting 15 minutes after closing, we will begin contacting you by phone. If we cannot reach you, we will attempt to call your emergency contacts by phone. We ask that you always provide us with at least three adult emergency contacts. It is extremely important to have up-to-date emergency contact information on file with us.

If you are more than 60 minutes late and we are unable to reach you or your emergency contacts, our staff will call Child Protective Services. MMA is responsible for your child’s protection and well-being until you or the authorities arrive.

MMA staff will not hold your child responsible for late pick-up and will address this issue with you directly, not your child. MMA will promptly inform you of any policy changes and other important notifications.

I have received, reviewed, and understand Mosaic Montessori Academy’s late pick-up procedure.

Parent Acknowledgement & Date

Parent Name *

Parent Name

Date of Acknowledgment *

Parent Signature *

Clear Signature

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Parental Commitment

Mosaic Montessori Academy or MMA is passionately committed to providing our students with a solid foundation for a life-long love of learning that promotes personal integration and understanding of independence. This belief and practice applies to all the students, and to their families as well. Communication & interaction between the family and the school is essential to this process.

MMA expects, if not requires, the parents to attend and participate in all of our planned Observations, Parent-Child Workdays, and Parent-Teacher Conferences, in addition to activities and programs that may highlight aspects of Montessori education and child development. Parent attendance and participation is critical to ensuring that your child experiences the full benefit of a Montessori education. Thus, we strongly recommend parental involvement as it enhances the partnership between home and school, creating optimal opportunities for the child’s development.

We, the undersigned:

Will be involved parents in behalf of our child.

We will observe in our child’s classroom at least one hour per school year (TBD).
We will attend scheduled conferences with our child’s teacher after each scheduled observation. We understand that additional conferences may be scheduled by either the parents or the teacher as need be.
We will endeavor to participate and help out in school events, celebrations, and programs planned by the MMA staﬀ, so that our child will experience wonderful memories.
We will make the scheduled Parent Information Nights a priority to help us get a deeper understanding of the Montessori Philosophy & child development.

Will support Mosaic Montessori Academy (MMA).

We will give our utmost support to the marketing and developmental eﬀorts undertaken by the school.
We will follow the guidelines of the Parent Handbook, and take full advantage of the Montessori experience oﬀered by MMA.

Parent Acknowledgment

Parent 1 *

Parent 1 Name

Parent 1 Signature *

Clear Signature

Parent 2

Parent 2 Name

Parent 2 Signature

Clear Signature

Date *

Health Exam Form

Health Exam *

I understand that I must print the State of Illinois Certificate of Child Health Examination form, have my child examined by an Illinois-licensed physician, and ensure that the same physician completes the form in full. I agree to submit the original, completed document to Mosaic Montessori Academy in River Forest, IL as a condition of this agreement.

State of Illinois Certificate of Child Health Examination form

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Program

Allergy & Medical Emergency Release

Student

Parents

Other Guardians

Doctor

Medical

Parent Authorization & Date

Contact Information & Pick Up Authorization

Student

Parent 1

Parent 2

If we are unable to pick-up our child, ONLY the following parties are authorized to do so:

Party 1

Party 2

Parent Authorization & Date

MMA Discipline Policy Acknowledgement

Parent Acknowledgment

Parent Handbook Acknowledgement

Parent Acknowledgement & Date

Student

Illinois State Late Pick-up Procedure

Parent Acknowledgement & Date

Parental Commitment

Parent Acknowledgment

DCSF Summary of Licensing Standards

Birth Certificate Requirement

Health Exam Form

Enrollment Agreement

Student Information

Parent Information

Emergency Contact

Program, Tuition, & Payment Information

Tuition Schedule – All Year

Tuition Schedule – School Year

Other School Fees

School Break Camps

Drop off and Pick Up Policy

Late Pick-up Policy

Compliance with School Policies & Right to Withdraw

Withdrawal and Tuition Refund Policy

No Waiver

Termination / Withdrawal Notice

Consent for Community Walks / Outside of School Activities

Consent for Use of Photograph and Videos on Social Media Platforms

Acknowledgement & Agreement

Montessori Affiliation

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