After School Program

Badger Time

(After School Program)

Registration Form

Hours: 2:20-6:30

Registration Fee: $65 (1 time fee)

Drop In□ Part Time□ Full Time □ Birthday _________

(One day, $30) (2-3 days, $50) (4-5 days, $70)

Student’s Name_________________________ Grade_________ Teacher_________________

Address__________________________________ Home #__________________________

City________________________________ State______________ Zip code____________

Parent email ________________________________________________________________

Mother’s Name_____________________ WK#________________ Cell#________________

Father’s Name______________________ WK#________________ Cell#________________

Emergency contact other than parent: _____________________________________________

Emergency Release

List all individuals who can pick up your child: (NOT INCLUDING PARENTS)

Name____________________________________ Phone#__________________________

Restricted Pick-Up:

List names of people who cannot pick up your child.

____________________________________ __________________________________

Special Instructions: (Allergies, Diet, Medical, Etc.)

_________________________________________________________________________

_____________________________________________________________________________________________________________________________

OFFICE USE ONLY

Registration Fee Paid $___________ Cash/Check#__________ Date______________

See Back

Parent Acknowledgment Statement

I understand that Badger Time is an afterschool program. The rules that are expected during the school day are expected to be followed while at Badger Time. I have explained the rules to my child and have made them aware of the consequences.

I understand that the discipline guidelines will be 1st a warning, 2nd a letter home, 3rd expelled from the program for 1 week and 4th a dismissal from the program.

I understand that I have given my permission for people named in the “Emergency Release” section of this form, to pick up my child from Badger Time.

I understand that all tuition fees must be paid by 6:30 on Wednesday or a $10 late fee will be charged to my account, unless prior arrangements have been made with the director.

If I am late picking up my child/children there is a $2 per minute late fee due, in cash, at the time that I pick up my children. The time will be decided by the school clock.

Child’s Name___________________________

Parent Signature_______________________

Date_________________