Badger Time
(After School Program)
Registration Form
Hours: 2:20-6:30
Registration Fee: $65 (1 time fee)
Part Time□ Full Time □ Birthday _________
(1-2 days, $50) (3-5 days, $75)
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#__________________________
Name____________________________________ Phone#__________________________
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 suspended 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 6:30PM Monday for the upcoming week. If payment is not made, a $10 late fee will be charged to my account the following Monday, unless prior arrangements have been made with the Badger Time Director. If fees goes unpaid the following Monday, the student will be suspended from Badger Time until all outstanding fees are paid.
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_________________