School Age Program Application

SCHOOL AGE PROGRAM APPLICATION

Green Trees Early Learning Center, Inc.

102 State Rt. 2001 Milford, PA 18337

Phone: (570) 296-9404

Child’s Name: ______D.O.B:______

Address: ______E-Mail: ______

______Application Date: ______

Home#: ______Allergies: ______

Mother’s Name: ______Father’s Name: ______

School Age Programs: Circle A, B, or C Elementary School: ______

A. AM Session ONLY 6:30-8:30 AM (includes delayed openings, breakfast $56.50/Week

If your child is scheduled for AM

session, and there is an early dismissal, will your child need the services of the PM session? (Additional Charge $10.00)

Yes ______No _____

Will your child be attending during scheduled school closings?SUBJECT TO AVAILABILITY

(If yes, you will be charged $20.00 per occurrence)

Yes ______No ______

B. PM Session4:00-6:00 PM (includes early dismissal, PM snack) $56.50/Week

Will your child be attending during scheduled school closings? SUBJECT TO AVAILABILITY

(If yes, you will be charged $20.00 per occurrence)

Yes ______No ______

1. BudgetSchool Age $113.00/Week

– This rate includes:

M-F AM Session*Delayed Openings*Breakfast

M-F PM Session*Early Dismissal*Lunch*PM Snack

Holidays

* MLK*Thanksgiving

Break

*Christmas Break*Columbus Day*Veteran's Day*Easter Break

ENROLLMENT FEE (Non-refundable): An initial registration fee of $35.00 is due at time of registration for new families. A subsequent re-enrollment fee will be charged for each enrollment.

Please note the following:

1. I agree to give two weeks written notice before withdrawing my child.
2. Tuition is due regardless of absence or holiday (no make-up days).
3. Weekly tuition/CCIS co-payments are due weekly, one week in advance.
4. The center reserves the right to refuse services if we feel a child’s continued enrollment will pose a danger to himself or others.
5. The center has the right to refuse services because of non-payment.
6. I agree to submit all annual documentation requested by the center.
7. I understand I am required to pay a security deposit equal to one (1) week of tuition due at time of enrollment.
8. I UNDERSTAND THAT I MUST CONTACT THE CENTER IF MY STUDENT WILL NOT BE IN ATTENDANCE FOR PM SESSION! ENROLLMENT WILL BE TERMINATED FOR FAILURE TO COMPLY WITH THIS POLICY ON MORE THAN 3 OCCASIONS.

Parent Signature:______Date:______

Green Trees Early Learning Center, Inc

102 State Rt. 2001 Milford, PA18337

Phone (570) 296-9404

Official Document Agreement for Child Care Services and Fees

*****************************************************************************

Name of Child______Weekly/ Fee:______

Attendance: M T W Th F Arrive:______Depart:______IN/ TOD/ PS/ PK/ SA

Name of Child______Weekly Fee:______

Attendance: M T W Th F Arrive:______Depart:______IN/ TOD/ PS/ PK/ SA

Name of Child______Weekly Fee:______

Attendance: M T W Th F Arrive:______Depart:______IN/ TOD/ PS/ PK/ SA

Security Deposit Amount:$______Registration Fee Amount:$______

Extended Care Surcharge :$______Weekly total:$______

*Tuition is due the Friday prior for the following week. You are required to pay your child care account weekly and maintain a $0 (zero) balance. If tuition is more than three weeks in arrears, you will be notified that your child’s enrollment has been suspended pending termination if payment agreement is not met.

*Notice of withdrawal must be provided on our withdrawal form and submitted at least two weeks prior to termination. Tuition will be due regardless of your child’s attendance until this form is submitted.

*There is no reduction or refund of tuition for absenteeism, holidays, emergency closings, withdrawals, or children sent home due to illness. There are no make-up days. You may request an additional day for an additional fee.

*Only one vacation week will be allotted each calendar year. Requests for use of vacation week must be submitted in writing two weeks prior to the requested week.

*Should enrollment agreement end and outstanding balances remain, the defaulted balance will be forwarded to collection agency at the client (family’s) expense.

*There will be a late charge of $1.00 per minute per child if child is picked up after 6:00 PM or 1PM for part time students. There will be a charge of $15 per day if a child is dropped off more than half an hour prior to designated drop off time or more than half an hour after designated pick up time unless authorized by the director.

*Maximum daily hours in care for full day students is 10hrs. Extended hours due to non-traditional work schedules may be granted at the discretion of the director, and an additional $5 per registered day will be charged for students ages 1-12.

*I have received and reviewed a copy of the Parent/Guardian Handbook. By signing this statement I agree to adhere to the policies indicated in the handbook. For the safety of students and staff, Green Trees requires that families of enrolled children agree to adhere to all Green Trees policies and procedures. If a family fails to comply with Green Trees policy after being reminded to do so, any or all children in that family may be asked to leave Green Trees and may not be permitted to return. Green Trees will refund unused tuition in the event a child is asked to leave for this reason.

–Initial____

OR

* I have elected to obtain parent handbook online at – Initial______

* I agree to submit Health Assessment form within 20 days of initial enrollment – Initial______

* My Student DOES / DOES NOT have an IEP/IFSP. If yes, a copy will be submitted – Initial______

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Parent/Guardian signature:______Date:______

Directors Signature:______Date:______

Date of child’s admission or date of change:______

Date of Withdraw: ______

Green Trees Early Learning Center, Inc.

102 State Rt. 2001 Milford, PA 18337

Phone: (570) 296-9404

EMERGENCY CONTACT FORM

Child’s Name: ______D.O.B:______

Address: ______Allergies:______

______Home #______

Mother’s Name: ______Home#if different______

Employer: ______Work #:______

Address: ______Cell #: ______

Father’s Name: ______Home # if different______

Employer: ______Work #: ______

Address: ______Cell #:______

Emergency contacts: (if parent cannot be reached)

NAME PHONE: (WORK/HOME/CELL)

1. ______W______H______C______

Address: ______Relationship: ______

2. ______W______H______C______

Address: ______Relationship: ______

3. ______W______H______C______

Address: ______Relationship: ______

Authorized Pick- up (other than mother or father as listed above)

May write SAA if Same As Above

NAME PHONE: (WORK/HOME/CELL)

1. ______W______H______C______

Address: ______Relationship: ______

2. ______W______H______C______

Address: ______Relationship: ______

3. ______W______H______C______

Address: ______Relationship: ______

My child may not be released to the following person (legal documentation required if person is parent/guardian):

Name: ______Relationship: _______

Parent Signature: ______Date: ______

Green Trees Early Learning Center, Inc.

102 State Rt. 2001 Milford, PA 18337

Phone: (570) 296-9404

EMERGENCY INFORMATION AND CONSENT FORM

CHILD’S NAME: ______DATE: ______

Written permission is given for: (Please check the following items in which you give permission)

_____Emergency Medical Care_____ Permission to share information with School District

_____First Aid by Staff/CPR_____ Application Sunscreen

_____Developmental/Health Screenings

_____Administration of Special Dietary or Dental Needs

_____Permission to contact Physician for Medical Information

_____Walking Trips

_____Water activities/wading (INCLUDING STEAM BY THE STREAM)

_____Photograph or Videotaping for publication, public relations/Press Releases, and Social Media.

_____Administration of Medication (Per physician’s instructions)

Are there any special medical or dietary information for management in an emergency situation – Allergies, Seizures or conditions including reactions and medication needs?PLEASE MARK N/A IF NOT APPLICABLE

Medical Problems: ______

Reaction Symptoms: ______

Medication Needed: ______

Has your child been vaccinated for chicken pox?YES______NO______

Has your child had the chicken pox?YES______NO______

Name and Address of Child’s Physician or Source of Medical Care:

Physician’s Name: ______Physician’s Phone#______

Address: ______

______

Insurance or Medical Assistance for your child:

Insurance Company:______

Subscriber’s Name:______

Group/Policy Number:______

Parent Signature: ______Date: ______