PLEASE PRINT CLEARLY. Child’s Name: Male/Female Grade Child’s School: D.O.B : Parent 1: Parent 2: Address: Address: City: Zip: City: Zip: Ph: (H) (W) (C) Ph: (H) (W)_ (C) Email: Email: Please check if you wish to be added to TCDN’s email list for center communications, including weather related information. TCDN will not sell your contact information.. Person responsible for payment: Phone: ( ) Address of responsible party Signature of responsible party My child is enrolling in the following TCDN program(s): (Two Day Minimum) Before School Club 7:15 - 8:30 # of days enrolled Specify days M T W TH F Monthly fee SASC (grades K-3) 3:30 - 6:00 # of days enrolled Specify days M T W TH F Monthly fee WASC (grades K-3) 3:30 - 6:00 # of days enrolled Specify days M T W TH F Monthly fee NPASC (grades K-5) 3:30 - 6:00 # of days enrolled Specify days M T W TH F Monthly fee OASC (grades 4-6) 2:30/3:30 - 6:00 # of days enrolled Specify days M T W TH F Monthly fee Total Monthly payment Effective the first day of school for the Wallingford Swarthmore School District 2015 through the last day of school for the WSSD 2016. In signing this contract, we accept and agree to the following: • There will be a $75.00 annual non-refundable registration fee for each child. • Full payment is due on the first of each month, in advance. A fine of $25.00 is levied for tuition not paid by the fifth of the month. A $20.00 charge is assessed on all returned checks. If there is a balance due from the previous year, your child may not attend until the account is paid in full. • For early dismissal and school closing days, pre-registration is required for ALL children attending. There is an extra charge for these days. Only children currently enrolled in TCDN programs can attend. See fee schedule. • THIRTY DAYS WRITTEN NOTICE MUST BE GIVEN TO THE MAIN OFFICE FOR ALL WITHDRAWS OR REDUCTIONS FROM ANY PROGRAM. • There will be no reduction of fees for days missed due to illness, vacation, emergency closings, scheduled holidays or closings. Fees are adjusted only for a serious or prolonged illness. This must be requested in writing. • There is a fine of $2.50 per minute for pick-ups after 6:00 PM. • Children with special needs must receive prior approval and submit requested IEP forms. • Families receiving subsidized care must contact the office prior to registration. • All enrollment forms must be filled out annually and returned before the child is to start the program and the Family Cooperative Contribution requireme...
PLEASE PRINT CLEARLY. Part I: To be filled out by the applicant along with the parent(s)/guardian(s) Student Name: Date of Birth: Home Address: City: State/Zip: Phone Number: SS# Do you currently have an IEP, 504 plan? YES or NO (Circle one) If you have an IEP, who is your case manager? Please provide the name(s) and phone contact(s) of your parent(s)/guardian(s) (unless you are live on your own) Parent/Guardian Name: Home Phone #: Cell or Work phone: Name of Emergency Contact: Home Phone #: Cell or Work Phone: Does the student have any medical conditions that we need to be aware of? YES or NO If yes, please list (be sure to turn in the proper medical forms to the CHS nurse as well): What is the student’s plan for transportation to and from the program? Part II: To be filled out completely by the student / applicant Please answer each question completely and LEGIBLY! Why do you feel you are a good candidate for the Missouri Option Program? What difficulties have you experienced in school in the past that has stopped you from succeeding? Why do want to enroll in the Missouri Option Program as opposed to getting your HiSET? Do you plan to go to college? What do you feel are your strengths and weaknesses? Part III: To be completed by the Missouri Option Program Coordinator[s] prior to student placement Name of student: Grade: _ Date of Birth: Age: Current Total Credits: Cohort Kindergarten: Is the student a 4th year senior? If not, what cohort graduation year? Has the student ever been retained? If so, how many years and when? Student’s plan for achieving the work requirement: Please answer yes or no to the following:
PLEASE PRINT CLEARLY. STUDENT FIRST & LAST NAME STUDENT # STUDENT SIGNATURE DATE NAME OF WITNESS WITNESS SIGNATURE DATE
PLEASE PRINT CLEARLY. Date Grade level of student Student’s Name Parent E-Mail Please print clearly. Address Phone Cell phone or beeper Emergency Contact phone Paid ($12.00. Please make check out to the Community Alliance.) The Wydown Middle School Indemnity Agreement In consideration of the acceptance by Wydown Social Committee Parents for the Community Alliance Program Activities of our child as a participant in the schedule for 6th, 7th, and 8th grade students in the 2008-09 season, and of similar agreements by the parents of other participants, we agree to indemnify the Community Alliance, the School District of Xxxxxxx, their Administrators, Teachers, Employees, and Agents (including the persons serving as chaperones) against loss, damages, or expense resulting from any claim or suit brought against the Community Alliance, the School District of Xxxxxxx, or any said persons (1) for any injury or damage which our son/daughter may sustain in connection with attending a social event and
PLEASE PRINT CLEARLY. COMMONWEALTH OF PENNSYLVANIA TO: Parents and/or Guardians FROM: Site Director SUBJECT: Nondiscrimination in Services Admissions, the provision of services, and referrals of clients shall be made without regard to race, color, religious creed, disability, ancestry, national origin, age or sex. Program services shall be made accessible to eligible persons with disabilities through the most practical and economically feasible methods available. These methods include, but are not limited to, equipment redesign, the provisions of aides, and the use of alternate service delivery locations. Structural modifications shall be considered only as a last resort among available methods. Any parent and/or their guardian, who believes they have been discriminated against, may file a complaint with any of the following: LifeSpan School and Daycare LifeSpan School and Daycare 0000 Xxxxx Xxxxx Xxxxx Xxxxxxxxx 000 Xxxxxxxxxx Xxxxxx Xxxxxxxxx, XX 00000 Xxxx Xxxxxxxxxx, XX 00000 LifeSpan School and Daycare 0000 Xxxx Xxxxx Xxxxxxx Xxxxxxxxxx, XX 00000 Department of Public Welfare PA Human Relations Commission Bureau of Equal Opportunity Philadelphia Regional Office Room 223, Health and Welfare Building Room 711, Philadelphia SOB P. O. Box 2675 0000 Xxxxxx Xxxxxx Xxxxxx Harrisburg, PA 17105 Philadelphia, PA 19130 U.S. Dept. of Health and Human Services Bureau of Equal Opportunity Office for Civil Rights Southeastern Regional Office Suite 372, Public Ledger Bldg. Room 1105-B, Philadelphia SOB 150 South Independence Mall West 0000 Xxxxxx Xxxxxx Xxxxxx Xxxxxxxxxxxx, XX 00000-0000 Xxxxxxxxxxxx, XX 00000-4088 Parent/Guardian Signature Date Rev. 3/11 Dear Parents, In order to post medical/allergy information about children, staff must obtain written permission from the parent. Please sign this form stating that LifeSpan has permission to post your child’s name on our medical/allergy posting. Thank you, LifeSpan ****************************** Child’s Name: Allergy/ Medical Condition: Parent/ Guardian Signature: Date: Registration fees: Billing Policies & Procedures Registrations fees are non-refundable. You will be charged $50 for 1 child; $75 for 2 children and $100 for 3 or more children at enrollment time. A security deposit is due for all enrollments prior to their start date. Your deposit will be refunded or used for your child’s last week of care at Lifespan, unless it is needed in the event your tuition is not paid. o The security deposit amount is equal to one week’s tuitio...
PLEASE PRINT CLEARLY especially the email address Student Name Student Cell # Student E-mail Text? Y N *NOT xxx000.xxx E-mail Parent/Guardian #1 Name Parent/Guardian #2 Name Cell # Cell# Addtl Phone # Addtl Phone#
PLEASE PRINT CLEARLY. Signature of Person Receiving Access: Print Name of Person Receiving Access: Job Title: Name of Employer/School: Date: Do you have a BMC Logician account? YES NO • If Yes, current BMC Logician Username: Current BMC Active Directory Account (AD Username):
PLEASE PRINT CLEARLY. Name Of Child: Age: Name of Parent/Guardian: Relationship: Contact Tel (Mobile/Home): email: Address: Signed by Parents/Guardian: Date Personal data collected are for the sole purpose of enrollment and will not be used for other purpose. Annex One Junior Snappers 2020 FILMMAKING CAMP is a private contracted summer camp(aka: class, course or workshop). Under the circumstance of Covid-19, rules and regulations are constantly evolving with short notice. Health and safety of the children is our first priorty and we will strive our best to ensure we maintain no more than 8 students in a class or the minimun allowance of group gathering by Hong Kong government. By enrolling your child in our camp. You have declared that your family and your children have not been out of Hong Kong in the last 14 days. Parents or caretaker have to check their children temperature ensuring it is below 37.5 degrees before allowing them to attend the camp. Parents and caretakers agree that they will not allow any children to attend the camp if their children have any signs of respiratory symptoms and flu-like illness. By signing your child to our camp, you acknowledge that it is not possible keep their mask on and social distancing during this filmaking camp. You agree to waive and hold harmless Junior Snappers and it’s holding company from any and all claims as a result of any illness that may be suffered by your children in the course of participation in its camp, courses and or workshops, and the activities incidental thereto. Signature of Parent/Guardian & Date Printed Name PLEASE NOTE THAT YOUR CHILDREN WILL NOT BE ALLOWED TO ATTEND OUR CAMP IF THIS CONSENT AND WAIVER IS NOT SIGNED.
PLEASE PRINT CLEARLY. (Financial institution name) (Branch) (Address) (City-State) (Zip code) (Routing/transit number) Type of Acct: Checking (Account Number) Savings This authority is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and manner as to afford COMPANY AND FINANCIAL INSTITUTION a reasonable opportunity to act on it. (print individual name) (print individual name) (signature) (signature) (date) (date)
PLEASE PRINT CLEARLY. Class Location: (Circle one) Meridian Junior High School; Dates for class: State License Number: P000195 Program Number: (Leave blank instructor will complete) State of Michigan Level 1 Driver’s License Number (Ex K 000 000 000 456) Date Level 1 license was validated by the Secretary of State: Full Name:
