Learning Oasis 2024/2025

The Learning Oasis

4000 N. 41st. Ct. Hollywood, Fl 33021
Name of person completing form:*

First NameLast Name
Today's Date:*

MonthDayYear
Child's Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Age:*
Parent's Name:*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Please list names and ages of brothers/sisters in the home:
Please briefly describe any concerns you have regarding your child's development. Please include any developmental delays or deficits. *
Please briefly describe any family member's significant developmental problems:*
Educational/Developmental Information
Your child's school:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Child's Grade: (If completing this form in the summer, please list grade that the child is entering)*
Teacher 1: Name and Number:*
Teacher 2: Name and Number
Does your child receive special education services- physical therapy/occupational therapy, speech/language therapy or behavioral services? If yes, please identify the name of the therapist(s) and briefly describe concerns. *
Was your child previously evaluated? (If yes, please email a copy of evaluation- readingwithliba@gmail.com) Please list any concerns that were voiced by the staff regarding your child's performance; general development or behavior:*
Has your child received reading tutoring in the past? If yes, please identify tutor's name and briefly describe the process and progress made. *
Do you have any concerns regarding your child's gross motor skills? (coordination, strength, sports, core and running)*
Do you have any concerns regarding your child's fine motor skills? (school skills, hand-eye coordination, strength)*
Has your child received swimming lessons? Is s/he at a beginners, intermediate or advanced level? Is your child comfortable swimming in a pool?*
Please list the sports your child likes to play:*
Please list the sports your child doesn't like /has difficulty playing:*
Please list any concerns in your child's diet and sleep hygiene:*
Please list any concerns with self-help skills: (dressing, eating, hygiene, food choices)*
When your child is overstimulated, frustrated or angry- what techniques do you feel are helpful for your child? *
How well does your child self-regulate? Please describe. *
What are your goals for your child?*
Medical Information
Please describe your child's birth history. List any complications during pregnancy, birth or infancy:
Please list any childhood illnesses and/or medical condition:*
Please list any current medications and reason for medication:*
Please list any allergies or food sensitivities: *
Does your child suffer from chronic ear infections?*
Has your child completed a hearing test? If yes, please record date of hearing test. Does your child have tubes in her/his ears, hearing aids or cochlear implant? Please describe. *
Has your child been seen for an eye exam? (developmental opthalmalogy or optometry) Please describe. *
Please list any activities that your child particularly enjoys or anything that may be useful as rewards:*
How did you hear about us?*
Additional Comments: Please write any further comments that you feel may assist our team:
What size t-shirt does your child wear?
I agree that these images or videos may be used for educational purposes and on social media.*

I confirm and give consent.I do not give consent.Other
I agree to sign the liability waiver prior to Sep. 3, 2024:*
In case of emergency, please list name and number:*

I agree to the following fee schedule for the 4 week program:

Oasis Program-Sep-Oct. 2024	Amount	Due Date
Deposit:	$2500.00	Upon Reservation
Payment 2:	$2500.00	9/1/24
Payment 3:	$2500.00	9/13/24
Payment 4:	$2500.00	9/27/24

Terms and Conditions:

The refund policy for the Oasis has a precise, fixed policy to deal with any scenario that may arise.

Do not sign below until you fully understand our refund policy. No exceptions will be made. Please contact us with any questions regarding our refund policy before signing.

Non-Refundable Fees: The initial deposit is $2500 and this ensures that your child has a reserved spot in the program. This non-refundable deposit will be applied towards the first week of the program. This payment cannot be transferred to other siblings or students. This non-refundable refund policy includes any COVID and health related reasons that one may have for not attending the program. Refunds will not be provided if you choose to withdraw from the program for any reason.

All families must have a credit card on file to be used for future payments. There is a 3% processing fee added to all credit card payments. If you wish to pay with a different method (Zelle) or make alternate payment arrangements, you may contact us to arrange an alternate plan.

This credit card will be used for all future payments.

In order for a session to run, there must be at least 5 students signed up for the program. If the program does not receive 5 or more reservations, the program will not run.

Drop off is between 8:50-9:00. The day will promptly start at 9:00 AM every day. We encourage all students to arrive a few minutes early. Pickup will be promptly at 3:00 PM everyday. Late pickup will incur a charge of $5/every minute after 3:05 PM.

Prior to the commencement of the Oasis program, every student will be given an arranged time to have a reading screening completed. This will enable every child to receive an individualized learning plan.

Thank you so much!

Looking forward to an incredible life-changing summer!

With love,

Liba

My Products*

The Learning OasisNon-refundable deposit to reserve a spot. This includes a 3% processing fee.

$2,575.00 Quantity

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The Learning Oasis

Educational/Developmental Information

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