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APPLICATION FOR CHILD CARE OR ENRICHMENT PROGRAM ON LAUSD CAMPUS
Type or print the following in cooperation with the school principal. Sign the “Terms and Conditions of Use,” and attach requested documents.
Operating Agency Phone ()
Name of Agency Representative Title
School Loc. Code Loc. Dist. School Calendar
Principal Phone ()
PROPOSED PROGRAM OPERATION
**FACILITIES MAY NOT BE USED UNTIL AUTHORIZED BY LEASING & ASSET MANAGEMENT**
Please note that groups will be charged for at least one hour of custodial overtime at an average rate ($31.00 per hour), utilities at $2.15 per hour and supply fees that can range from $2.00 - $15.00 per day.
DATES AND TIMES OF OPERATIONDates / Times / Please specify days of use (i.e., daily, only Mondays)
From: / To: / From: / To:
From: / To: / From: / To:
From: / To: / From: / To:
From: / To: / From: / To:
From: / To: / From: / To:
From: / To: / From: / To:
Program Type: Child Care Enrichment Other
(Please check all that apply)(Please specify)
Before School After School Winter Break Summer Recess Spring Break
Grade Levels Served Ages Served Number of Students
Please identify type of room/facility to be used:
(i.e., multipurpose room, gymnasium, auditorium, field)
IMPORTANT NOTE: Applicants for your child care or enrichment program must be advised that admission to your program does not guarantee enrollment in the regular educational program at this school.
Signature of Principal Date Signature of Agency Representative/TitleDate
BULLETIN
TERMS AND CONDITIONS OF USE
NOTE: SUBMITTAL OF THIS APPLICATION DOES NOT GRANT YOUR AGENCY A LICENSE TO BE ON CAMPUS. NO GROUP CAN OCCUPY AN LAUSD CAMPUS WITHOUT FIRST OBTAINING A LICENSE AGREEMENT ISSUED BY THE LEASING & ASSET MANAGEMENT BRANCH OF THE LOS ANGELES UNIFIED SCHOOL DISTRICT.
This is a cost-incurred license based upon certain assumptions related to the cost of the program. The Los AngelesUnifiedSchool District requires the following certification:
I certify that any money derived in excess of the cost of operation of the child care or enrichment program for which I have applied shall be returned to the program to reduce the cost to participants.
District-sponsored programs, including but not limited to intervention, summer school, tutoring and national school lunch program, will supersede these terms and conditions.
______
Signature of Agency Representative/Title Date
FORWARD THE SIGNED APPLICATION WITH ATTACHED DOCUMENTATION TO THE LOCAL DISTRICTLOCAL DISTRICT SUPERINTENDENT/DESIGNEE
APPROVED: Yes No ______Date ______
FORWARD THE SIGNED APPLICATION WITH ATTACHED DOCUMENTATION TO BEYOND THE BELL BRANCHBEYOND THE BELL BRANCH
APPROVED: Yes No
______
Assistant Superintendent/Designee Date
Extended Day Program
ATTACHMENTS
Prior to approval by the Beyond the Bell Branch, the following documents must be submitted with the application:
- Evidence of advertisement of student fee waiver for at least 25 percent of participants
- Fee schedule
- Copy of nonprofit designation
- Proof of liability and property damage insurance
- Copy of Department of Social Services license (for child care programs only)
- Agency operation rules and regulations, including sign-in/sign-out requirements
- Incorporation papers (for parent groups only)
BUL-2525.1Page 1 of 2ATTACHMENT A
July 13, 2006