Registration Form: 2017/2018 After School Program
After School Program at North Branch Arts for Grades KG-6
Name of Child: / Grade:Parent/Guardian Name:
Address: / City: / ZIP Code:
Phone Number: / E-mail:
Emergency Contact Name:
Phone Number: / Relationship to Child:
Who else may pick up your child? Name______Relationship:______
Please explain allergies/medical conditions we need to be aware of:______
Please check the boxes for the days your child will attend.
Monday / Total cost of the program (per child) is divided into 9 equal monthly payments plus a half payment for June (final day of the program is June 18th). The first payment is due prior to the first day of the program (September 5th); it serves as a non-refundable deposit and is your September payment. All other payments are due the first of each month.Member Costs are below (annual membership is $250);please see northbrancharts.org for non-member cost/month for each program.
Please circle your monthly payment (per child) below.
Tuesday
Wednesday
Thursday
Friday
Member Cost/Month / Non-Member Cost/Month
5 days/wk / $350 / $440
4 days/wk / $300 / $365
3 days/wk / $230 / $275
2 days/wk / $155 / $185
1 day/wk / $80 / $95
Please complete this form by signing below and submit with first payment prior to the first day, September 5th. Please make checks out to North Branch Arts. Forms/payment may be mailed or dropped off (through the mail slot in the front door)to 5421 West Devon Chicago, IL 60646.
I hearby release North Branch Arts, its agents and employees, from all liability for personal injury, illness or property damage occurring on or off the center’s premises. I have read the registration information and understand that I am responsible for the related payments as described. I certify that my child is in good health and capable of participating in park play and art/craft projects. I hereby give permission for North Branch Arts employees/volunteersto meet my child at Edgebrook School, to supervise play at Edgebrook Park, Jeff Green Park, and/or North Branch Arts Community Garden, and to walk my child to North Branch Arts. I hereby give permission for my child to participate in art projects and to be included in photographs for promotional use for the program (brochures, North Branch Arts website, North Branch Arts Facebook page).
______
Parent/Guardian SignatureDate
North Branch Arts5421 West Devon, Chicago, Illinois 60646 northbrancharts.org