Camp Chip-A-Tooth

Camp Chip-A-Tooth

Office Address 459 Rio Grande Ave. New Castle CO 81647

Beyond the Bell Before and Afterschool Program Enrollment & Permission Form (GSES and/or Sopris)

PLEASE FILL OUT THIS FORM ONLY IF YOUR CHILD IS ATTENDING THE

BEYOND THE BELL BEFORE (6:30am-7:45am) OR AFTERSCHOOL PROGRAM(3:30-6:00pm)

STUDENT ENROLLMENT FORM~

Morning Program or Afternoon Program or Both ______Enrollment Date: ______

Child’s Name:______Date of Birth: ______Age:_____

Days of the week child will be Attending Beyond the Bell (Morn. Or Afternoon Program or Both) ______

Grade and Teacher:______

Child’s Home Address: ______

Parent’s Address if different than child: ______

Child’s Home Phone: ______Parents home phone if different than child: ______

Email ______

Mother’s Name:______Father’s Name:______

Work. No.: ______Work No.: ______

Cell No.:______Cell No.: ______

Place of employment ______Place of employment ______

Work Address: ______Work Address: ______

IF neither parent of guardian can be reached, in case of emergency, call:List name, Phone numbers and address: These Persons are authorized to pick-up your child if needed: ______

Persons who are NOT legally permitted to pick-up your child: ______

Child’s Doctor include Number and address: ______

Dentist include Number and address: ______

Allergies and/or health concerns: ______

AttachImmunization Records (required asap)** ALL INFORMATION ABOVE IS REQUIRED. Must have a Doctor and Dentist name.

Authorization for child to view “G” and “PG” rated videotapes

I give my permission for my child to view “G” and “PG” rated videotapes at Beyond the Bell.

Dated:______By:______

Signature of Parent or Guardian

After School Program…Authorization for Child to Sign Himself/Herself in:I give permission for my child to sign him/herself in to the program. Beyond the Bell accepts no responsibility for ensuring the attendance and arrival of the child. As a courtesy, we attempt to contact parents by phone if their child does not sign-in to the program. It is the parent’s responsibility to ensure the classroom teacher, the child and Beyond the Bell know the days of attendance and that updated phone numbers are on file with the school and Beyond the Bell.Dated: ______By:______Signature of Guardian

*additional form MUST be signed if your child will be signing themselves out at the end of the day.

Before School Program Authorization for Child to Sign Himself/Herself out:I give permission for my child to sign him/herself out of the program at 7:45 a.m. Beyond the Bell accepts no responsibility for ensuring the attendance or arrival of the child to their homeroom at the start of the school day. At the end of the program your child will be directed to go to breakfast in the cafeteria. Dated: ______By:______Signature of Guardian

Field Trip/Activity Authorization:I give my permission to Beyond the Bell and/or its employees to take my child on walking field trips, use of public transportation/BTB 15 passenger Van and school buses and for my child to participate in any of the activities associated with the program. I understand that my child’s participation in this program, in general, could involve various risks, hazards and dangers which may include risks of physical harm and injury due to participating in the activities or traveling to and from locations outside of the school facility. I understand that Beyond the Bell undertakes every reasonable effort to make the activities safe, but I also recognize that it is impossible to guarantee the safety of each individual involved in such activity or to guarantee that the activity will proceed exactly as planned. I hereby assume all risks that could be posed to my child and indemnify and hold harmless Beyond the Bell, its staff, agents and employees from any liability, claim, cause of action or demand arising from my child’s participation in this program.

Dated:______By:______

Signature of Parent or Guardian

Medical Authorization: In case of serious illness or injury when neither parent can be reached, will you allow your child to be transported to the doctor or hospital by an employee of Beyond the Bell? ___YES ___ NO

I hereby give permission to Beyond the Bell to secure emergency medical and/or surgical treatment for the above named minor child while in the care of the above named school. All expenses of such care will be accepted by the parents. . I will hold the Beyond the Bell staff, agents and employees harmless and indemnify them from any claim, cause of action or demand arising out of any form of (or lack of) medical or emergency treatment rendered to the student.

Dated: ______By:______

Signature of Parent or Guardian

Acknowledgement of Policies and Procedures:I have read and understood the policies and procedures of Beyond the Bell:

Dated: ______By:______

Signature of Parent or Guardian Please enclose $25 annual family registration fee. Make checks payable to Beyond the Bell. 2017/2018 Beyond the BellAfter School Program!!!

WHAT IS BEYOND THE BELL AFTERSCHOOL PROGRAM and HOW DOES IT WORK?

Beyond the Bell, is an afterschool extracurricular activities program and state licensed childcare. Our program offers a convenient way for students to participate in positive, educational and fun afterschool activities right at the school. Beyond the Bell is open right after the bell rings until 6:00pm. Kids check into the program right after the bell rings at the end of the day. They get a snack and programming is from 4:30pm – 5:00pm. (Wednesdays programming 2:30-3:30 and 4:30-5:30)While at Beyond the Bell students can complete their homework, build positive relationships with other students at the school, and choose to participate in extracurricular programs all while in a safe and friendly environment.

The first day of Beyond the Bell will be September 5th Beyond the Bell Fees:

Fees include an afterschool snack, supervision, and programming, are based on monthly enrollment and are per child: (The rates below are not the rates for Wednesdays) Wednesdays will be $ 20 per Wed. (2:00-6:00). Or $15 2:00:3:30ttended unless your child is full time.)

(AFTER SCHOOL PROGRAM RATES, IF YOU WANT MORNING PROGRAM SEE BELOW)

  • One day a week is $60 per month ($15 per day)
  • Two days per week is $120 per month ($15 per day)
  • Three days per week is $180 per month ($15 per day)
  • Four days per week is 240 per month ($15 per day)
  • Five days per week is $ 282per month ($13 per day)(exception Wed $18.50 per day)
  • Drop in is available for $17.00 per day (enrollment and registration fee does apply) $22 WED
  • 10 Punch Pass is available for $160 (must be prepaid)
  • Beyond the Bell may choose to accept CCCAP assistance (Wednesday Drop In $22 per day)

There will be a registration fee of $25 per year per family. Enrollment forms can be picked up at the front office and returned to students’ teacher or the front office. For more information on signing your child up for Beyond the Bell please callCrystal 707-631-3993

Programa de Después de la Escuela De Beyond the Bell!!! QUE ES BEYOND THE BELL( MAS HAYA DE LA CAMPANA)?

Beyond the Bell, Inc. es un programa extraescolar y cuidado de niños después de la escuela. Nuestro programa ofrece un modo conveniente para que los estudiantes participen en actividades positivas, educacionales y divertidas después de la escuela. Beyond the Bell comienza depuse de la campana hasta las 6:00 pm. Durante Beyond the Bell, los estudiantes pueden terminar sus tareas, construir relaciones positivas con otros estudiantes en la escuela y participar en actividades extraescolares todo en un ambiente seguro y sano. Beyond the Bell es un programa licenciado por el estado. El primer día de Beyond the Bell será el 5de Septiembre. y continuara durante el año escolar. Beyond the Bell estará cerrado durante vacaciones reconocidas y cierre de las escuelas.

Costos de Beyond the Bell: Los costos incluyen un bocado después de la escuela, supervisión, un programa divertido, los cuales están basados en una inscripción mensual por niño:

Un día de la semana es $60 por mes *Dos días de la semana es $120 por mes *Tres días de la semana es $180 por mes

  • Cuatro días de la semana es $240 por mes *Cinco días de la semana es $282 por mes

Programas extraescolares son un extra de $16 por mes por actividad Habrá un costo de registracion de $25 por año por familia.

Formas de inscripción pueden ser recogidas en la oficina principal y regresadas a la maestra del estudiante o la oficina principal.

Para mas información en inscribir su hijo/a en Beyond the Bell por favor llame a Crystal a 707-631-3993

NEW THE 17/18 SCHOOL YEAR BEFORE THE BELL MORNING PROGRAM

Beyond The Bell is offering a morning program from 6:30-7:45 due to bridge construction the 17/18 school year. At 7:45 the program will end and the kids will sign them selves out of BTB. We will offer a morning snack, homework help, and organized activity and interact with the children in a way that will set them up for a successful day at school. (If you need the after school program too, please see the above Prices for both morning and afternoon program together to get the total for both programs.

  • One day a week is $40 per month ($10 per day)
  • Two days per week is $80 per month ($10 per day)
  • Three days per week is $120 per month ($10 per day)
  • Four days per week is $160 per month ($10 per day)
  • Five days per week is $180 per month ($9 per day)
  • Drop in is available for $12.00 per day (enrollment and registration fee does apply)
  • 10 Punch Pass for Drop ins- $110(must pre pay)

beyondthebelldaycamp.com 707-631-3993

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