PLEASE PRINT CLEARLY. Part I: To be filled out by the applicant along with the parent(s)/guardian(s) Part II: To be filled out completely by the student / applicant Please answer yes or no to the following:
PLEASE PRINT CLEARLY. Child’s Name: Male/Female Child’s School: D.O.B : Address: City: Zip Code: Email: Person responsible for payment: Phone: ( ) Address of responsible party Signature of responsible party After School Club** 3:30 - 6:00 # of days enrolled Specify days M T W TH F Monthly fee 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 required 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 requirement must be fulfilled during the school year. (All forms are available at xxx.xxxx.xxx). Scholarship help is available through the Stuppy Memorial Fund. Please contact the Director for more information. Guardian Signature Date Director Signature Date BEFORE SCHOOL CARE – (Swarthmore After School Club site)
PLEASE PRINT CLEARLY. COMMONWEALTH OF PENNSYLVANIA
PLEASE PRINT CLEARLY. Name Of Child: Age:
PLEASE PRINT CLEARLY. STUDENT FIRST & LAST NAME (your child)
PLEASE PRINT CLEARLY. STUDENT FIRST & LAST NAME STUDENT #
PLEASE PRINT CLEARLY. Signature of Person Receiving Access:
PLEASE PRINT CLEARLY. Water Department Account #(s): (Financial institution name) (Branch) (Address) (City-State) (Zip code) (Routing/transit number) (Account Number)
PLEASE PRINT CLEARLY especially the email address
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 2010-11 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
