NY City Explorers: Afterschool Contract 110 Schermerhorn Street, Brooklyn, NY 11201 - 718.797.3707 186 Underhill Ave, Brooklyn, NY 11238 – 718.399.6923
Name of Child ______Date of Application______Birth date ______Age ____ M / F
* Allergy Alert * Does your child have allergies? Yes / No: To What? ______
Parent(s) or Guardian(s) Contact Information:
Name ______Relationship ______Home Phone______Cell/Work______
Home Address ______City ______State _____ Zip ______
Name ______Relationship ______Home Phone______Cell/Work______
Home Address ______City ______State _____ Zip ______
We always try to contact parents first. However, we are required to have emergency contact: OTHER THAN parents. These people are also authorized to pick up your child from the NYCE Afterschool Adventures program. You must fill out a temporary pick up authorization each time your child is to be picked up by someone else in a non-emergency situation. Please list all appropriate emergency phone numbers:
Name ______Relationship ______Phone ______/______
Name ______Relationship ______Phone ______/______
Medical Provider ______Phone ______
Insurance Information (if applicable) ______
My Signature gives permission for the following:
In an emergency, NYCE Afterschool Adventure Program has my permission to call an ambulance or to take my child to any available physician or hospital at my expense and to obtain medical treatment for my child. In most emergencies, 911 is called and child is transported to nearest hospital and seen by Dr. on call. (Parents are always notified as soon as possible) Please list any restrictions to permission: ______
______My child may be applied sunscreen or antibacterial first aid cream and ointments. Syrup of ipecac may be administered if deemed necessary by a poison control operator.
______My child may be photographed for publicity or news purposes: ______on site ______off site ______web site
______Afterschool Adventures requires enrollment in our automatic flex-payment monthly billing system. We additionally allow monthly payment by check or money order. There is a 2.5% credit card processing charge for any payments made via credit card. Check or money order payments may only be dropped off at our 3rd floor office or given directly to office staff and may not be given directly to any afterschool staff. Please note that no cash is accepted. Payment is due for your registered days despite your family’s attendance. There are no refunds for afterschool fees. If your family departs from the program, the entire amount due for the remaining registered afterschool session will be charged to the parent/guardian. NYCE Afterschool program reserves the right to collect all fees due and any collection and/or legal fees will be charged to the parent in the event of debt collection and/or report said indebtedness to the credit bureau and/or military command. All payments are due on the 28th of every month starting August 2012.
______Participation in Afterschool Adventures is contractual. Your weekly schedule is not amendable from week to week and is locked-in on a per-session basis. A schedule must be committed to for the entire session. Afterschool Adventures follows the NYC public schools calendar, and dates that school is not in session, Afterschool Adventure is not in session. NY City Explorers offers School Break Adventure Camp trips on many of those dates, excepting major holidays, and families enrolled in Afterschool Adventures are invited to attend with a 10% discount.
______I understand that late payments will be assessed a $35 fee. If your payments fall more than 1 week behind, your child may lose their space in the NYCE Afterschool Program.
______I understand that upon acceptance to Afterschool Adventures, I must pay the required 1 month deposit. This deposit will be applied to my last month’s fees.
______A $35 NSF fee will be assessed if my check is returned by the bank. If I have 2 NSF checks within a 6 month period, I will be required to pay by credit card or money order.
______I understand that I must pick my child up on time at dismissal. Should I arrive late, I will be assessed late fees as outlined in the parent letter payable the following afterschool date. If I am consistently late, a meeting will be held with the director and my child’s enrollment may be terminated.
______I have read and understand the NYCE Adventure Camp Head lice policy and will report lice infestation of any member of my family to my child’s teacher immediately.
Please initial the requested sessions and days:
____FALL Sep 6, 2012 - Dec 21, 2012 ____ Jan 2, 2013 – Mar 22, 2013 ____ Apr 3, 2013 – June 26, 2013
____MONDAY ____TUESDAY ____WEDNESDAY ____THURSDAY ____FRIDAY
By signing I agree to all the above conditions, fees, and permissions and I certify that I have read and understand the NYCE Afterschool program policies and procedures and will abide by all conditions set forth in the preschool parent letter.. An official schedule change dated later than this contract will supersede the original schedule commitment effective four weeks after the change submission. This directive is a legal and binding agreement and all conditions set forth will be enforced.
Parent/Guarding Signature ______Date ______
Explorers Academy Preschool Administrator ______Date______
Center Use Only Schedule Change Added ______
General Information
Has your child had previous afterschool experience? Yes ____ No ____ Type of program ______How long? ______
Please give any information concerning your child, which will assist us in providing the best care for your child:
Play ______
______
Eating habits and schedule ______
______
Fears ______
______
Likes and dislikes ______
______
Special words and meanings ______
______
Other Children in the household:
Name/ Nickname of child ______Age ______Sex ______
Name/ Nickname of child ______Age ______Sex ______
Name/ Nickname of child ______Age ______Sex ______
Does your child have allergies? Yes ____ No _____ Has your child had chickenpox? Yes ____ No _____
What types of allergies or other health problems does your child have, and what do we need to know to provide the best possible care? Do these restrict your child’s activities?
______
______
______
FOR STAFF USE ONLY
Required Forms on File □ Enrollment Contract □ Medical Form □ Immunizations □ ______□ ______