The Excel Program Registration Form
Student Information
______
Last First
______/_____/______
Grade Age Birth date Sex
______
Street Address City, State Zip Code
PARENT/GUARDIAN INFORMATION
Father: ______Employer:______Work Hours: ______
Home: ______Work: ______Cell: ______
Email: ______
Mother: ______Employer:______Work Hours: ______
Home: ______Work: ______Cell: ______
Email: ______
Guardian: ______Employer:______Work Hours: ______
Home: ______Work: ______Cell:______
Email: ______
Person(s) Responsible for Payment:
Name(s) ______Social Security Number(s) ______
Address(es) ______
Student lives with (check all that apply): [ ] Father [ ] Mother [ ] Guardian
Is there a court order protecting the custody of this child? ___ Yes ___ No
If yes, a copy of the court order must be included with this registration.
EMERGENCY CONTACTS & Student Pick Up
In the event the parents/guardians cannot be reached, the school will call the people listed below. People listed should be individuals who can: 1) give permission to administer health care; 2) pick up your child if your child is ill; and 3) give advice about caring for your child.Please list people who you authorize to pick up your child(ren) from the Excel childcare program. (Must show identification when picking up)
Name: ______Name: ______
Phone Number: ______Phone Number: ______
Relationship to student: ______Relationship to student______
HEALTH INFORMATION
Physician: ______Phone: ______
Dentist: ______Phone: ______
Medication(s) being take by student: ______
Physical conditions (allergies, diabetes, etc.): ______
If I, my child’s emergency contacts listed above, or the physician listed above, cannot be reached in an emergency, I authorize school employees or legal representatives to obtain emergency medical care for my child while under the school’s care including transporting or sending my child to an available hospital or physician.
Signature ______Date: ______
I authorize the Excel Program to administer Tylenol for minor aches such as a headache.
Signature ______Date: ______
Statement of Health
I do declare that the child named on this contract is in good health and is able to
participate in all activities offered by the Excel Program.
______
#1 Parent/guardian signature Date
Parent Contract
I am enrolling ______in the after school and/or summer program. Enrollment, which is on a first-come, first-served basis, is completed upon receipt ofrequired formsincluding full payment (registration fee and 1 week’s fee). Tuition payments are due on Monday of each week, or monthly. Payments received after 6:00 p.m.on Fridays are considered late. Accounts 10 days past due will result in suspension from the program until balance is paid in full - this includes late pick-up fees. I understand that in the event of nonpayment, I am responsible for all costs of collection (A collection cost of 35% of the delinquent balance will be added to the delinquent balance for collections).
(Your signature indicates acceptance of all policies and regulations of the Excel Program)
______
#2 Parent/guardian signature Date
I have received the Excel Program Parents’ Handbook, the parent handbook has fully informed me about the policies and procedures of the Excel Program. Among other topics, I have now been informed about the policies and procedures of discipline; homework; the release of children; tuition, fees, and payment structure; and termination from the program. This handbook will serve as a quick reference source to answer questions on policies and procedures.
______
#3 Parent/guardian signature Date
Permission
Name of child: ______
Photographs
Yes, I give permission for my child’s photograph to be taken for use by the Excel Program publications and for release to local newspapers.
No, I do not want my child to be photographed.
Videotaping
Yes, my child may participate in videotaping for recreational purposes only.
No, I do not want my child to be videotaped.
Blanket Permission for Walking Trips
Yes, I give my child permission to participate in walks around the school’s
campus.
No, I do not want my child to go on walks.
Field Trips
Yes, I give my child permission to participate in field trips off campus.
No, I do not want my child to go on field trips.
______
#4 Parent/guardian Signature Date
Withdrawal Procedure- 2week notice
Notification of withdrawal must be given in writing two weeks in advance. If notification is not given tuition is still required for the next two weeks whether your child attends or not.
Summer Program Vacation Week Procedure
During the summer program one vacation is given to students who enrolls for the entire summer program. Students who enroll after the program begins, or withdrawals before the summer program ends will not receive a vacation week. The directors must be notified at least two weeks prior to vacation dates in order for the students to receive credit for the week.
I have read ad understand Withdrawal and Vacation Procedures
______
#5 Parent/guardian SignatureDate
A completed registration includes:
Registration Form - an original registration form must be received.
Payment must be included (Registration Fee and 1st Week’s Tuition).
A copy of immunization
______
After School Program
Check one:
______Full-Time
______Part Time Which days? Mon. Tues. Wed. Thurs. Fri. (circle)
______Enrichment Day Which day? Mon. Tues. Wed. Thurs. Fri. (circle)
______
Summer Program
Check one:
______Full-Time
______Part Time Which days? Mon. Tues. Wed. Thurs. Fri. (circle)
______