Eclectic, Holtville, Millbrook, Wetumpka (Circle One)

Elmore County Public Schools - Child Development Program

Registration Form

School Year 2017 – 2018

PLEASE ENROLL MY CHILD IN (CIRCLE ONE):

Eclectic:K3K4Afterschool Grade ___Holtville:K3K4Afterschool Grade ___

Millbrook:K0 K1K2K3K4Afterschool Grade ___Wetumpka:K2K3K4Afterschool Grade ___

SCHOOL YEAR 2017-2018SUMMER 2018

6 wks to 12 mos.Tuition: $125 Per Week6 wks to 12 mos.Tuition: $125 Per Week

Pre-K1 Tuition: $115 Per WeekPre-K1 Tuition: $115 Per Week

Pre-K2 Tuition: $105 Per Week Pre-K2 Tuition: $105 Per Week

Pre-K3,Pre-K4 Tuition: $90 Per Week Pre-K3, Pre-K4 Tuition: $90 Per Week

K-6th Gr Tuition: $90Per Week

Afterschool Care

Tuition: $50Per Week

Legal Name: / Date of Birth:
Nick Name: / Gender: / Race:
Address: / City, state, zip:
Home Telephone Number: / Grade for 17-18: / School:
Parent/Guardian Name (mother): / Cell phone:
Employment: / Work Phone:
Parent/Guardian Name (father): / Cell Phone:
Employment: / Work Phone:
Step Parent: / Cell Phone:
Employment: / Work Phone:
Email Address:
Are there any custody issues in which we should made aware? If yes, please explain:
YES NO / Please attach official documentation from court to this form if a parent is not allowed to see the child or to pick up the child from daycare.
Does the child have an Individualized Education Program (IEP)?
YES NO / If yes, an IEP team meeting will be held prior to the child attending the program to ensure that appropriate accommodations will be provided as needed.
Are there any medical conditions in which we should be made aware (allergies, nosebleeds, etc.)?
YES NO / If yes, please explain:
Does the child have Health Insurance:
YES NO / If yes, name of insurance company and contract number:
Do we have permission to seek medical attention if we are unable to contact parents?
YES NO / Please sign here giving permission to seek medical attention if we are unable to contact parents:

Revised August 2017

List three names and telephone numbers to call in case of an emergency.

(1)

(2)

(3)

List individuals and their telephone numbers that have permission to pick up your child other than parent/guardian. A child will be released only to individuals listed below. These individuals must show photo ID when picking up child from the program.

(1)

(2)

(3)

Terms and Conditions of Enrollment

  • I understand there is a registration fee of $30 per child due upon registration. This fee is recurring and is due annually by August 1st for each child enrolled.
  • I understand that Tuition Rates are as follows:

Fulltime/Summer/Holiday TuitionAfterschool

6 weeks to 12 months = $125 per weekKindergarten – 6th Grade = $50.00 per week

Pre-K1 = $115 per weekDiscounts

Pre-K2 = $105 per weekAdditional Children = $5.00 discount per week

Pre-K3 and up = $90 per weekPay Monthly by 1st Monday of Month = $5.00 discount per week*

*Discount applies to Fulltime Tuition Only

  • I understand that tuition is due on Mondayby 6:00 p.m. I may pay weekly, bi-weekly, or monthly;however, payment is due the first Monday of service.
  • I understand that payment must be made with check or Money Order. Cash cannot be accepted for tuition.
  • I understand payment made after Monday is subject to a $10.00 late fee.
  • I understand that tuition rates are based on registration and are not influenced by attendance.
  • I understand that if my child(ren) does not attend the Child Development Program during school holiday weeks, I am responsible for paying a fee of $55.00 per week per child for children in the Infants to Pre-K2 classes. A fee of $50.00 per week per child will apply for children in the Pre-K3 and up classes.School holiday weeks areFall Break, Thanksgiving, Christmas/New Year, and Spring Break.
  • I understand that when afterschool children attend a full day, an additional $8.00 fee will be charged, if in attendance.
  • I understand that when school is released early, an additional $5.00 fee will be charged, if in attendance.
  • I understand that program hours are 7:00 a.m. to 6:00 p.m. If my child(ren) is picked up after 6:00 p.m., I will be charged a $15.00 fee per child for the first fifteen minutes and an additional $1.00 per child for each minute thereafter.
  • I understand that is my responsibility to keep the program informed with up to date contact information.
  • I understand that when I withdrawmy child from the Child Development Program, I must give a two weeks’ notice and pay any outstanding balances.

I have read, understand, and agree to the above listed Terms and Conditions of Enrollment. Please enroll my child in the Child Development Program.

Parent/Guardian SignatureDate

Revised August 2017

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