Iyápi Glukínipi | Owáyawa Číkʼala

Lakota Language Initiative|Lakota Immersion Montessori Program Child Application

Thank you for interest in our Lakȟóta Immersion Montessori Program. We believe in delivering high-quality Indigenous Early-Childhood education through our Lakȟóta language and life-ways. Our approach is the Montessori Method which allows for the child to develop the necessary skills, language and independence to navigate our world.

We have two Montessori environments at both sites. Ages 1-3 (1 walking stable) and Ages 3-6 (Fully Potty Trained).

This online application is only a placeholder on the waitlist. You will be contacted either for your initial parent interview and/or when we are looking to enroll your child in the program. Thunder Valley CDC staff does take precedence.

Montessori Location Interested In:

Pine Ridge School Location (Pine Ridge, SD) Thunder Valley Location (Porcupine, SD)

Child's First Name:

Child's Last Name:

Lakȟóta Name:

Nickname:

Date of Birth:

Children ages 3-6: Is your child fully potty trained? (A child is considered potty trained when they need no assistance using the restroom and no longer uses a diaper day or night)

YesNoNot Applicable

Home Address (city/state/zip):

Mailing Address (city/state/zip):

Phone Number:

Email:

Allergies & Other Medical Conditions (i.e. asthma, diabetes, epilepsy, physical limitations, etc.):

Parent/Guardian First and Last Name:

Relation to Child:

Email:

Work Phone:

Home/Mobile Phone:

Work Schedule:

City/State:

Of your workplace

Parental Marital Status:

Custody Arrangements:

Individual(s) restricted from seeing/picking-up child:

Emergency Contacts

Name:

Relationship:

Phone:

Name:

Relationship:

Phone:

Who will regularly pick-up child(ren):

Name:

Relationship:

Vehicle:

Name:

Relationship:

Vehicle:

Any other additional information you would like to share? (favorite foods, likes/dislikes, fears, special interests, etc.)

Emergency Medical Care Authorization

I hereby give permission for emergency medical treatment for my child (enter name in space below) if requested by the TVCDC Owáyawa Číkʼala | Lakȟóta Immersion Montessori Program.

Child's Name Authorizing Emergency Medical Treatment For:

Please note that my child is allergic to the following medications:

It is also important to note that my child has the following special medical condition(s):

I/We attest that the information listed on this application is as accurate and complete as possible.

Signature

By typing my name below, I am electronically signing my application

Date:

Signature:

By typing my name below, I am electronically signing my application

Date: