Intent To Start At Mosaic

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Please fill out this form only when you are absolutely sure about your child's start date. Once this form has been filled out with your child's start date, it cannot be changed. We look forward to welcoming your family to the Mosaic family.

Mosaic Location *

Mosaic Early Childhood Academy (Chicago)

Mosaic Montessori Early Childhood (Skokie-Oakton) (Full Time Only)

Mosaic Early Childhood Center (Skokie-Dempster)

Start Date *

YYYY

Parent's Name *

Child(ren)'s Name(s): *

Child(ren)'s Date(s) Of Birth *

Child(ren)'s Age(s): *

Phone Number *

Email Address *

Which program are you signing up for? *

Full Time Program - All locations

Part Time Program Option 1 (3 Days: Monday, Tuesday, Wednesday) - Skokie-Dempster only

Part Time Program Option 2 (2 Days: Thursday, Friday) - Skokie-Dempster only

Part Time (1-4 days/week) - Chicago-Addison only

By writing my full name (first and last name) below, I am signing up my child to start at Mosaic on the start date above in accordance with the schedule above. I understand and agree to abide by all the policies set forth in Mosaic's Parent Handbook and all addenda, including but not limited to, the COVID-19 Addendum to the Mosaic Parent Handbook. *

By writing my full name (first and last name) below, I agree to disclose to Mosaic any cases of COVID-19 in my household and cooperate fully with Mosaic. *

By writing my full name (first and last name) below, I understand that, upon submission of this form, I agree to pay Mosaic a two-week deposit per child immediately via phone using credit or debit card (my child(ren)'s site director will call me to process this payment). This payment will be put towards my child(ren)'s final two-weeks and will be forfeited in the event that I do not provide a two-week written notice of dis-enrollment. This payment will also be forfeited in the event that I choose to delay my child(ren)'s enrollment beyond the start date indicated on this form or cancel my child(ren)'s enrollment all together. I further understand that the two-week tuition deposit may be in addition to a registration fee, depending on my enrollment status. *

Preferred Daily Drop Off Time *

Preferred Daily Pick Up Time *

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