Queen of Peace After School Registration 2020-2021



Name of Father:__________________________*# to contact: ___________________ email:____________________Name of Mother: _________________________*# to contact: ___________________ email: ____________________*In case of emergency, what is the best number to reach you between 2:35pm-5:30pm weekday?*Name of Child/ren:Grade:List any Allergies:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Cost of Service: $3.00/hour per child. $1.50/half hour per child.Schedule of Service: Please place a mark for the schedule option that best fits your needs. ScheduleDescriptionYour ResponsibilityRegular/ Permanent____________________Your child/ren attend(s) the program on a weekly basis.Fill out initial registration schedule with days of week and time of pick-up for each day. This will be done on a monthly basis. Failure to fill out schedule may result on loss of your child/rens spot. If changes occur, make changes to schedule by 5:30 pm of the Wednesday prior to attendanceWeekly____________________Your child/ren attend (s) the program on a weekly basis, but days and times vary.Same as AboveOn-Call____________________Your child/ren attend(s) the program occasionally.Fill out initial registration. If possible please complete schedule by 5:30 pm of the Wednesday prior to the week of attendance. If the same day you will be automatically billed for 1 hour. Fees:Missed PaymentLate FeePaid before due date of next billing cycle$5No payment$10No payment outstanding$10 + $5 for each additional week without paymentPayment schedule for the first month of attendance:Billing will be generated on a weekly basis and payment for your childcare account must be paid in full. Regular/Permanent and/or Weekly scheduling may choose to make payments weekly or bi-weekly, due on Fridays. On-Call payments will be due within one-week of child's attendance. Payments are due by the date listed on your statement. If not paid on time, late fees will be applied. *Please make checks or money orders to: Queen of Peace Catholic School.I affirm that the above information is true and correct to the best of my knowledge. I understand the possible fees that can accrue on my account due to late or no payment, unless otherwise arranged with the After School Director. It is my responsibility to inform the After School Program staff of intended attendance or absence by the Wednesday prior to attendance or absence or as soon as possible. If changes in this information occur, it is my responsibility to notify After School staff of those changes. I am the only person(s) allowed to make changes to this form.Parent/Guardian Signature:______________________________________ Date: ______________________Parent/Guardian Signature:______________________________________ Date: ______________________ ................
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