OCSD Elementary School Extended Day Program Registration Form Child(ren)’s Last Name ______
All outstanding balances must be paid in full prior to registration in a future program.
PLEASE PRINT OR TYPE
Name(s) of Child(ren) Grade School Program Days
______GP RS VV AM PM M TU W TH F Drop-in
______GP RS VV AM PM M TU W TH F Drop-in
______GP RS VV AM PM M TU W TH F Drop-in
______GP RS VV AM PM M TU W TH F Drop-in
Address ______Home Phone ______
Parent/ Guardian Information:
Name ______Work Phone ______
Address (if different) ______Cell ______
email: ______
Name ______Work Phone ______
Address (if different) ______Cell ______
email: ______
List 2 local emergency numbers different from those listed above (obtain permission from individuals):
Name(s) Phone Relationship to child(ren)
1. ______
2. ______
For After School Program ONLY: In addition to the individuals listed above, please list the names of other persons who have permission to pick up your child(ren) from the After School Program:
Name(s) Phone Relationship to child(ren)
1. ______
2. ______
Signature of Parent/ Guardian ______Date ______
EXTENDED DAY PROGRAM AGREEMENT
2017-2018
Please Print:
Name(s) of children)______GP RS VV
Name(s) of person(s) responsible for payment: ______
DSS Childcare Subsidy: In the case of DSS Childcare Subsidy, the parent is responsible for all outstanding balances not paid by Otsego County DSS. Additionally, the parent is responsible for all paperwork required by Otsego County DSS.
Choose your participation/ payment plan. This participation/ payment plan will stand for the full school year and may only be changed ONE TIME during the school year. Requests for participation/ payment plan changes must be made in writing to the Site Coordinator.
_____ My child(ren) will attend on a regular basis (check all that apply and fill-in amount due):
___ Elementary AM Program (1st child) $35/ month………………………………………………………………………$35
___ Elementary AM Program (additional children) ____ children x $25/ month………………………………………$___
___ Elementary PM Program (1st child) $85/ month………………………………………………………………………$85
___ Elementary PM Program (additional children) _____ children x $75 month……………………………………....$___
· I understand that I am responsible for the total monthly fee of $______.
· The monthly fee is due by the 1st of each month.
_____ My child(ren) will attend on a Drop-in basis:
· I understand that children who attend on a Drop-in basis must notify the site coordinator by e-mail, written note, or a phone call to the school office. I may indicate multiple dates on the same notice.
· I understand that should I choose to use the program on a ‘drop-in’ basis, I will be charged for the days I use even if my payment exceeds the regular monthly fee.
· AM Program Drop-in fee: $4/ day for each child
· PM Program Drop-in fee: $9/ day for each child
· I understand that I must choose to make payments in one of the following ways (please choose one):
___ Per Service: Payment by check or cash on the day of service. The site coordinators cannot make change.
___ Monthly Billing: The Site Coordinator will keep track of the number of days of service during the month and a bill is generated at the end of the month. Failure to make timely payments may result in suspension of your drop-in privileges.
In consideration of enrollment in the Oneonta City School District Extended Day Programs, the following additional assurances are given:
· I have read the terms and conditions of the programs and am familiar with its contents;
· I understand there is no nurse/ medical staff on duty during the program. It is further understood that no employee or volunteer is authorized to administer medication;
· I understand the monthly and daily fee structure for the program and agree to pay accordingly. I may make one change to my registration agreement during the year and that change must be requested in writing;
· I understand that if payment is not made when due, my children may be removed from the program until payment is made in full;
· I understand there is a late fee assessed for pick up after the designated pick up time, as indicated by the terms and conditions. Repeated tardiness will result in my children’s removal from the program.
· I understand that no students may attend the program free of charge.
· I understand that fees are due the 1st week of each month for all monthly users and payment for drop-in users is due according to the choice I have indicated above. Delinquency in payment will result in suspension from the program until all fees are paid in full.
· I understand that childcare subsidy may be available through the Department of Social Services for those families who qualify and that it is each family’s responsibility to apply for and maintain paperwork through the Department of Social Services.
______
Parent/ Guardian Signature Parent/ Guardian Name (please print) Date