St. Michael School Before and After Care Program 2016- Registration Form 2017 Name Grade Age Sex Birth date Name Grade Age Sex Birth date Name Grade Age Sex Birth date Mother's Name. Business Phone Father's Name Business Phone. Home Address Home Phone 1, A child may not enter the Aftercare Program unless this registration agreement is signed by the parent(s) or guardian(s) legally responsible for the child(ren), 2. Tuition payment. Monthly tuition is due and payable on the first (ist) day of the month. Write child(ren)'s name on the face of the check, indicating “Aftercare Program.” 3. Suspension. child is suspended from the program for non-payment of tuition on the first (Ist) day of the month, A child remaining on suspension for more than three (3) days is dropped from the program. 4, Withdrawal. Tuition for Aftercare will be refunded for withdrawals as follows 75% through the 5th day of the month 50% through the 15th day of the month No refund after the 15th day of the month Attendance, There are no tuition refunds or deductions for absences, holidays or vacations. 6. Late Pick-up. Late pick-up fees are as follows (due at time of occurrence and will be strictly enforced): Regular Day: (2:50 p.m. to 5:30 pm.)....$20.00 Extended Day: (after 5:31 p.m)....additional $10.00 I (We) have read the Extended Day Handbook and the above items. I (We) agree to abide by these rules and terms. Mother/Guardian Signature Father/Guardian Signature Date Date 4St. Michael School 2016. Before and After Care Program Bt Emergency Information 2017 In case of any emergency and parents cannot be reached, call: Name Relationship Phone Doctor Clinic Phone Alternate Doctor Clinic Phone Insurance Coverage: Company: Policy #: Health problems We, as parents/guardians of hereby grant permission to St. Michael School to have our child(ren) treated by a physician selected by the ‘school if our child(ren) named above are injured in an accident and need emergency treatment during program hours. This permission is granted only if we and our family physician cannot be reached by phone. Parent/Guardian Signature Date Parent/Guardian Signature Date PARENTAL AUTHORIZATION FORM Thereby grant the following persons to escort/pick up my child(ren) from Saint Michael Aftercare Program. (List anyone who may pick up your child. No child will be released to anyone not on this list.) Name Relationship Business Phone Home Phone Comments/Additions/Deletion to above list: 42