MERIDIAN SCHOOL TRIPLE A ENRICHMENT PROGRAM ARTS ACADEMICS ATHLETICS REGISTRATION PACKET

Triple A - Arts Academics Athletics - Meridians Enrichment Program

1. The Triple A Enrichment Program provides a safe and stimulating environment for Meridian students after school. The
program offers both competitive and non-competitive art, academic, and athletic programs.

Options

Hours

Description Snack Study Hall Age appropriate enrichment activities Outdoor/Indoor Recreation Interactive cultural and community presentations $225/month/student $200/month for each additional sibling $200/month for Meridian School staff beyond 4:00pm Outdoor/Indoor Recreation Interactive cultural and community presentations $50/month/student $45/month for each additional sibling Free for Meridian School staff
Various Art, Academic and Athletic Programs (See Program Overview)

Mon/Tues/Thurs/Fri 3:00pm-6:00pm Full-Time Wednesday 1:00pm to 6:00pm

Early Release Wednesday

Wednesday 1:00pm to 3:45pm

Independent Program

Varies

2. A full registration packet must be filled out for each student. If registering multiple students, please staple the familys
registration packets together. Packets must be completed and submitted in full at least 2 weeks before intended student start date for Full-Time and Early Release. Registration packet must be completed and submitted in full at least 24 hours before intended student start date for Independent Programs.

3. Late pick-ups from Triple A will result in additional fees to accrue at the rate of $5.00/5 minutes. Late begins at 6:01.
These charges may be withdrawn by automatic draft the following day.

4. Payment is due via bank draft the fifth of each month for automated draft programs. 5. Same policies apply to behavior, etc. as are noted in the student handbook and Code of Conduct. 6. Please note that adjustments might be made in fees at a later date to provide a sliding scale to address the needs of our
families and to reflect the quality of the programming.

7. All fees paid to Meridian School are non-refundable. 8. Feel free to contact the Triple A Enrichment Program Coordinator Monique Swain at m.swain@mwschool.org if you have
any questions.

Parent Signature

Date

MERIDIAN SCHOOL TRIPLE A ENRICHMENT PROGRAM | REGISTRATION PACKET

STUDENT INFORMATION
NAME (LAST, FIRST, MI)__________________________________________________________________ GENDER Male Female DATE OF BIRTH ____/____/____ GRADE (2011-2012)________________ ADDRESS________________________________________________________________________________

PARENT/GUARDIAN #1
NAME (LAST, FIRST, MI)__________________________________________________________________ ADDRESS________________________________________________________________________________ EMAIL ADDRESS___________________________________EMPLOYER__________________________ HOME PHONE______________________________ WORK PHONE_______________________________ CELL PHONE_______________________________ ALTERNATIVE PHONE_______________________

PARENT/GUARDIAN #2
ELIGIBLE TO PICK UP CHILD? Yes No (If no, please attach a copy of legal documentation) NAME (LAST, FIRST, MI)__________________________________________________________________ ADDRESS________________________________________________________________________________ EMAIL ADDRESS______________________________EMPLOYER_______________________________ HOME PHONE____________________________ WORK PHONE_________________________________ CELL PHONE______________________________ ALTERNATIVE PHONE________________________

EMERGENCY CONTACT
Local person (18 years of age or older) other than those listed above to contact in case of emergency if the parent/legal guardian cannot be reached:

NAME_______________________________________RELATIONSHIP TO CHILD___________________ CONTACT NUMBER__________________________ CONTACT NUMBER________________________ ADDRESS________________________________________________________________________________

ADDITIONAL ADULTS AUTHORIZED TO PICK UP

In addition to those listed above, I hereby authorize the Meridian staff to allow my child to leave the facility with only the following persons (must be 18 years of age or older):

NAME_________________________________________RELATIONSHIP TO CHILD_________________ CONTACT NUMBER_________________________CONTACT NUMBER__________________________ ADDRESS________________________________________________________________________________ NAME_________________________________________RELATIONSHIP TO CHILD_________________ CONTACT NUMBER_________________________CONTACT NUMBER__________________________ ADDRESS________________________________________________________________________________ NAME_________________________________________RELATIONSHIP TO CHILD_________________ CONTACT NUMBER_________________________CONTACT NUMBER__________________________ ADDRESS________________________________________________________________________________ NAME_________________________________________RELATIONSHIP TO CHILD_________________ CONTACT NUMBER_________________________CONTACT NUMBER__________________________ ADDRESS________________________________________________________________________________

MERIDIAN SCHOOL TRIPLE A ENRICHMENT PROGRAM | REGISTRATION PACKET

EMERGENCY INFORMATION
In the event of an emergency and a parent/legal guardian is not available, your designated physician, hospital, or clinic will be contacted for emergency management/transportation (please refer to the medical waiver below):

LICENSED PHYSICIAN NAME_______________________________ PHONE______________________ ADDRESS________________________________________________________________________________ HOSPITAL OR CLINIC NAME_______________________________ PHONE______________________ ADDRESS________________________________________________________________________________
In order to best meet your childs needs, we require that you list any special needs that your child may have, such as physical limitations, emotional or behavioral issues, allergies, existing illness, previous serious illness, injuries during the past 12 months, any medication prescribed for long-term continuous use, and any other information the staff should be aware of:

__________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

PARENT/GUARDIAN ACKNOWLEDGEMENTS
Please INITIAL all lines to indicate that you reviewed these written policies/materials and agree to terms. _____ Policy Agreement (REQUIRED): I acknowledge that I have been made aware of where to access or have received a copy of Meridians Triple A Program Facts. I accept responsibility to read and adhere to all billing procedures and all policies as set forth in that document. _____ ADA Policy (REQUIRED): Parents have the obligation to disclose significant medical, physical, or behavioral issues at the time of the childs enrollment and on an ongoing basis. Due to the large group format of our program, we are unable to provide one-on-one care for any child except on an intermittent basis, such as injuries, immediate disciplinary issues, and certain personal care needs customarily provided to other children. _____ Waiver for Medical Treatment (REQUIRED): In the event that my child requires emergency medical treatment and I cannot be reached, I hereby authorize the Meridian staff to make arrangements to transport my child to the physician, hospital, or clinic that I have designated above, or to the nearest hospital/emergency medical facility. I give my consent for any and all necessary medical care treatment for my child during this time. _____ Waiver for Participation (REQUIRED): I understand that Meridian activities have inherent risks and hereby assume all risks and hazards as a result of my childs participation in all Meridian programs and facilities, including transportation to and from said activities. I further release, absolve, indemnify, and agree to hold harmless, Meridian, the organizers, supervisors, directors, staff, volunteers, participants, coaches, referees, as well as persons or parents transporting participants to or from such activities from any claims or injury sustained during my use of Meridian facilities or participation in any Meridian activity, whether located on Meridian property or not. _____ Waiver for Photo/Video/Audio Release (OPTIONAL): I give my consent for any photos, video, and/or audio taken of my child involved in Meridian programs to be used for Meridian promotions, trainings, and/or displays. _____ I understand that withdrawal from the program requires two weeks written/faxed notice. I also understand that Meridian reserves the right to dis-enroll my student for non-payment and/or behavioral issues. _____ I understand that my tuition is due on or before the 5th of each month. Failure to pay before the 6th of the month will result in a $25 late fee and could possibly result in removal from the program.

PARENT/GUARDIAN SIGNATURE___________________________________DATE________________

MERIDIAN SCHOOL TRIPLE A ENRICHMENT PROGRAM | REGISTRATION PACKET

Health Information & Forms 2011-2012 Medical Considerations

If your child takes any medication on a daily basis, whether taken at home or at school, please list below.

Student Name Medication Name Dosage/When to administer

Physician Contact Information Primary Physician Address Telephone Number

Clinic

Allergies & Special Health Needs Does your child carry an EpiPen? Yes No If yes, for what reason? __________________________________________________________________________________________ If your child has any allergies or special health needs, please include below. Allergy/Special Need Notes

MERIDIAN SCHOOL TRIPLE A ENRICHMENT PROGRAM | REGISTRATION PACKET

PAYMENT FORM
All students are required to have automated draft information completed for late pickup expenses (if incurred) Only one form of Draft Payment may be entered per student. Please see the Meridian School Triple A Enrichment Programs Overview for a list of programs and payment methods. List the name of each student and the name of the program(s) below Only one payment form needs to be filled out per family if fees for siblings will be paid via the same account. If amending an existing payment form, please completely fill out the form with the all the program(s) the student(s) will be enrolled and indicate the updated draft amount.

Step 1: Check the box that applies: First-time payment form (Student not currently enrolled in any Triple A Enrichment Programs) Amendment to an existing payment form (The family already has a registration form on file but the payment form needs to be updated.)
STUDENT NAME PROGRAM(s) NAME STUDENT NAME PROGRAM(s) NAME STUDENT NAME PROGRAM(s) NAME STUDENT NAME PROGRAM(s) NAME STUDENT NAME PROGRAM(s) NAME

ACCOUNT HOLDERS ADDRESS CITY/STATE/ZIP PHONE NUMBER

MERIDIAN SCHOOL TRIPLE A ENRICHMENT PROGRAM | REGISTRATION PACKET

STEP 2: For one-time fee programs

ACCOUNT TYPE ONE-TIME AMOUNT CREDIT CARD # CREDIT CARD EXP. DATE CARDHOLDERS NAME Checking Savings Credit Card [ Master Card Visa] (Amount: $____________)

For monthly automated draft programs and late pickup

ACCOUNT TYPE DRAFT AMOUNT CREDIT CARD # CREDIT CARD EXP. DATE CARDHOLDERS NAME
*Voided check required. Please attach in indicated spot below.

Checking*

Savings*

Credit Card [ Master Card

Visa]

Monthly on the 5th (Amount: $____________)

AUTOMATED CLEARING HOUSE (ACH) DRAFTS ARE REQUIRED TO HAVE A VOIDED CHECK. DEBIT CARDS ARE NOT ACCEPTED. MUST BE ACH OR CREDIT CARDS ONLY.

1. I understand that this transfer will occur monthly on the 5th of each month for checking/savings and credit card drafts. The first 2. 3. 4. 5. 6. 7.
draft begins September 5th. I understand that should I choose to terminate or change Bank Accounts, Banks, Account Types, or Child Care Plan in any way, I must provide Meridian with at least a 2-week written notice prior to my transfer date. I understand that the information above will be used to transfer payment from my account. I understand that if my payment is returned for non-sufficient funds (NSF) for any reason, the item(s) will be re-presented electronically and I understand that I will be charged a $30 non-sufficient funds (NSF) processing fee. I am also responsible for all other recovery costs. I understand that if my account has a late pick up fee or a late payment fee, the amount may be drafted from my account on the next draft date. Meridian only accepts Master Card and Visa. I understand that after three returned items, I will be ineligible to use the automatic payment option. My account will then become cash or money order only.

ACCOUNT HOLDER SIGNATURE________________________________DATE________________

PLEASE STAPLE A VOIDED CHECK HERE

MERIDIAN SCHOOL TRIPLE A ENRICHMENT PROGRAM | REGISTRATION PACKET