APPLICATION FORM
CHILD’S NAME:______
ADDRESS:______
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TEL# HOME:______
CELL:______
EMAIL:______
D.O.B:______
GRADE:______
SCHOOL:______
PARENT OR GUARDIAN:______
EMERGENCY CONTACT NAME:______
TELEPHONE:______
ALLERGIES/FOOD ALLERGIES :______
______
ILLNESSES:______LEARNING DISABILITIES ______
WHAT TO DO IN THE EVENT OF A MEDICAL EMERGENCY?
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PICK UP PERSONS :______
The Little WiseChild After School Program
3607 Palmer Ave, Bronx, NY 10466 3530 Edson Ave, Bronx, NY 10466
Telephone : 917 363 7983 Telephone: 917 359 1765
The Little Wise Child will provide After School services under the following conditions:
Parents must pay first week, last week and registration fees at time ofregistration.
All fees must be paid on time.
Fees are expected every Friday (before start of each week or before 11:00 am
on Saturday, or there will be a $20 late payment fee.
______Child(ren) must be picked up at time agreed upon (6:30pm) by both parties. If
parent/guardian is late, the amount of $5.00 will be charged for each additional
15 minutes starting at 6:45. Fees are due on the same day. If the late fee is not
paid by the Friday the fee will be doubled
______There will be an additional $10.00 charge, for half day school schedule and
$20.00 for the days the children do not go to school.
Parents will be responsible for paying the regular weekly fee of $90.00 for the
days the after school director is available, whether child attends or not.
No one other than parent/guardian and person(s) listed on emergency information
form will be permitted to pick up child(ren).
______Kids cannot be picked up before 5:45( except in the case of an emergency) from
Afterschool. It is an inconvenience to both the staff and the focus of the remaining children concentrating on work.
______All extracurricular activities are an integral part of the afterschool and all children are required to come prepared. After three violations or absences of this
rule, kids who forget items such as swimwear, sweatpants and sneakers etc. will not be able totake part in other extracurricular activities.
Children with a highly contagious illness will not be admitted to the after school
unless the parent presents a written statement from the physician certifying the
child is well enough to return to the program. (this rule applies to child(ren) who
may have lice and ring-worm etc)
If child does not attend school, or gets picked up early because of illness
parents need to notify director of absence by 2:00 p.m. the latest. After 3
violations your child will be left behind at school if they do not show up at the
meeting place on time.
If child does not attend after school on a particular Friday, parents must still
make the effort to pay the dues on that Friday.
______Parents are expected to send in a copy of their child’s progress report each
quarter in order for us to better assess the child’s strengths and weaknesses.
If fees are not paid by Saturday before 11:00 am, and there has been no
communication I will not be held responsible for picking up your child from
school on the following Monday.*
______I will be responsible for practicing spelling and vocabulary words with my child on the weekends, so they are better prepared for the test.
______The program will usually be available during the Winter, Spring and February
school breaks. The program hours are 8:00 a.m.- 5:30p.m. The fee will be
$145 for these weeks. These are the only three weeks in the school year that parents do not have to pay if child does not attend.
Each child must be provided with his/her own lunch when there is no school
scheduled .
______There is no double parking or blocking of our neighbors drive way on
Palmer Ave. If this is discovered your child will be dismissed from the
program immediately and the last weeks fee will not be refunded.
If parent refuses to pay for extended vacation or absences, child(ren) will be
terminated immediately.
This contract is valid for a year. The only circumstances under which its terms
no longer apply are the following. In the case of job termination, dismissal from
Afterschool, a change in location, or if parents are displeased with service.
Please note that two weeks’ notice is required.
I have read and understand the terms of this agreement.
Child’s Name : ______
Parent’s Name : ______
Parent’s Signature Date
AGREEMENT
PLEASE COMPLETE AND RETURN
It has been agreed that will pay
Parent/ Guardian
($90.00) weekly for the care of .
Name of Child
An advanced payment of ($180.00) is required at registration to cover both the first and last week's fees in addition to a $50 non-refundable registration fee. The total to be paid at time of registration is $230.
The following activities are included in the price above.
-Swimming lessons
-Karate
-Soccer
-Art
-Tennis
-Chess
-Mad Science
-Culinary Arts
-Sewing
-Culinary Arts
-Basketball
-Baseball
We also offer gymnastics, dance, piano and ice skating lessons for an additional cost.
I have read and understand all the terms of this agreement
Parent’s Signature Date
THANK YOU.
Little Wise Child Afterschool Program
3607 Palmer Avenue, Bronx, NY 10466
646 469 8630
FIELD TRIP PERMISSION
This is to certify that I
(name of parent)
give permission for my child
(name of child)
to travel by foot, private vans, charter buses and by public transportation
under the supervision of counselors in order to attend trips related to
the after school and summer camp program.
Parent Signature: Date:
This permission slip is valid for one year from date of signature
*FOR RETURNING PARENTS ONLY*
Please provide 3 reasons why you are re-enrolling your child in the program.
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