FCPS



Coach’s Club After-School ProgramEnrollment Information2020-2021Applications can be found on the website: applications are also on the Garden Springs Elementary website under: Quick Links, Coach’s Club, Registration.Non-Refundable Enrollment Fee: $30 for 1 child, $40 for 2 or more siblingsPayment is made via auto draft every two weeks or otherwise noted on the payment schedule.**CCAP is not accepted at this location.Available spots are first come, first serve. Waitlists do occur, please do not wait to turn in your application.left781685To be completely enrolled, you need to turn in:Completed applicationRegistration FeeVoided CheckImmunization Certificate020000To be completely enrolled, you need to turn in:Completed applicationRegistration FeeVoided CheckImmunization CertificateIf you have any questions, contact Cheryl Zimmerman: Cheryl.zimmerman@fayette.kyschools.usCoach’s ClubGarden Springs Elementary After School Care Program2020-2021 School Year Registration FormOne application per child. Registration is not complete without all forms and registration fee received and approved.All fees are Fayette County Public School board approved. The registration fee is $30 per child or $40 for families with more than one child. If a child(ren) is unenrolled from the program, upon return, the registration fee must be paid again.??? Child’s Name ______________________________________ Gender (circle one) ?????MALE ???FEMALE ????????????????Age ________________ DOB:__________________ ???? School Year Grade ___________ ?Home Address_____________________________________________________________________________Primary Phone Number_________________________Email________________________________________ Mother/Guardian’s Name_______________________ Work Phone________________________________ Cell Phone___________________________________ Work Place_________________________________ Father/Guardian’s Name________________________ Work Phone________________________________ Cell Phone____________________________________ Work Place_________________________________Emergency Contact Information – Someone other than those listed aboveEmergency Contact Name ___________________________________ Relationship to child ______________Emergency Contact Home Phone Number _______________________ Cell Phone _____________________Release Authorization – Those who are allowed to pick your child upNameRelationship to ChildPhone NumberHealth Information*If your child has a 504 plan or an IEP, please feel free to let the directors know how these impact your child’s care in the after school program*List any health, physical or developmental limitations__________________________________________________________________________________________________________________________________________________________________________ List any allergies_______________________________________________________________________Does your child take prescription medicine on a daily basis? ??□ Yes □ No Will your child take prescription medicine during programming hours? ?□ Yes □ NoDoes your child have an emergency medication/inhaler/epi-pen on file at school? ????□ Yes □ NoList medications and dosage in the event of medical emergency__________________________________________________________________________________________________________________________________________________________________________ Hospital Preference ___________________________________________________________________ PaymentCoach’s Club accepts automatic debit authorizations only. Registration fees are to be paid to Garden Springs Elementary in the form of cash, check or money order at the time of registration. Any returned check will result in a $20 return check fee. Late fees are expected at the time of pick up. Any fee that is not paid will result in suspension or denial of the after school program.Child Care AssistanceAt this time, Coach’s Club does not accept Child Care Assistance provided by the state. All families are responsible for each payment to the program. The information listed is accurate to the best of my knowledge, and the child herein described has my permission to engage in all activities. In the event that I cannot be reached in an emergency, I hereby give permission to the Garden Springs After School Program Director(s) or designee to secure emergency medical services including transportation and a physician. I have read and understand the Coach’s Club after school program parent handbook. Parent/Guardian Signature ______________________________________ Date __________________Coach’s ClubCharge RequirementsCharges $55/week - (1-5 Days Week) Registration Fee* $30 per child or $40 per household *Registration fee is required at the time of enrollment. Registration fees are non-refundable. Charges for participation in Coach’s Club covers the cost of snacks, art supplies, crafts, and staffing. By signing this contract, you are agreeing to pay Garden Springs Elementary for after school care for the 2020-2021 school year. The following guidelines will be used when evaluating your good standing in the program: Fees will only be collected by automatic withdrawal. Personal checks and/or cash will not be accepted for monthly payments. Charges are not refunded due to sickness, vacations, family emergencies, or availability of another childcare provider.A late charge of $1.00 per minute will be charged for any child picked up later than 6:00pm. The charge is due at the time of pick up. Your child may resume attendance once this fee is collected.In the event an automatic withdrawal is returned for insufficient funds or a closed account, contact will be made one time in an effort to collect tuition. If your account does not have sufficient funds, you will be responsible for any additional charges incurred from the collection of the returned automatic withdrawal.Coach’s Club is not in session during days that school is closed. If a snow day occurs, your monthly payment will not change. Fees will simply be transferred to the additional make-up days later in the school year. Failure to adhere to the Garden Springs Elementary School behavior policy, acts of physical aggression, violence, or threats towards students or staff, may result in immediate dismissal from the after school program. This decision will be made at the discretion of the site director, principal or designee.Program WithdrawalYou have the option of withdrawing from Coach’s Club at any time during the school year. However, once the month has begun, tuition for the entire month will be charged. Readmission to the program is not guaranteed once you have withdrawn. We respectfully request a two week notice with completion of a withdrawal form. The program withdrawal form must be turned in for documentation, and the program director will work with you to set up the last auto-draft payment. Readmission to the program is not guaranteed once you have withdrawn. If you wish to re-enroll, you will be placed on a waiting list and notified if a space becomes available. The registration fee will be charged each time a family enrolls in the after school program.Tax Information/ReceiptsYearly tax statements will be provided each year at the end of January. Monthly statements are provided at your request. Please allow at least one week for the statements to be provided. I, _____________________________________________________________,have read the financial agreement and agree to abide by the above financial guidelines. Failure to abide by the financial guidelines can/will result in your child’s suspension/dismissal from the program.Parent/Guardian Signature ___________________________________________Date: ______________________________________*Without this form signed, your application may not be considered complete and does not guarantee a spot in Coach’s Club After School programPlease return to site director. The site director will then process the form and get in touch with you about the status. This may take up to 3 days.Student Name: ________________________________________________________________Date: ________________________________________________________________________Garden Springs Elementary47625616585AUTOMATIC DEBITAUTHORIZATION AGREEMENTI hereby authorize Garden Springs Elementary School (Coach’s Club) to initiate the automatic debit entries to the account listed below. I understand the automatic debits will only be posted to my account for the date and amount I have listed below.This authorization will remain in effect until Garden Springs Elementary has received written notification from me at least 10 days prior to the next scheduled debit date.Signature: _________________________________________________________________020000AUTOMATIC DEBITAUTHORIZATION AGREEMENTI hereby authorize Garden Springs Elementary School (Coach’s Club) to initiate the automatic debit entries to the account listed below. I understand the automatic debits will only be posted to my account for the date and amount I have listed below.This authorization will remain in effect until Garden Springs Elementary has received written notification from me at least 10 days prior to the next scheduled debit date.Signature: _________________________________________________________________Coach’s Club After School ProgramAutomatic Debit Entries Information:Dates/Fees: * Please see attached fee scheduleBank Account Information for Debit:Financial Institution Name: _______________________________________________________Financial Institution ABA Number (Routing Number): ___ ___ ___ ___ ___ ___ ___ ___Individual Account Number: ______________________________________________________This is a _________ checking account ______ savings account (Check one)To have Registration Fee drafted, please sign here: ________________________Note: A voided CHECK must be attached below if the account is a checking accountCoach’s Club Fee ScheduleDate of Auto DraftAmountDays Paid ForAug. 5$91Aug. 12-21Aug.19$110Aug. 24 – Sep. 4Sept. 2$110Sep. 7-18Sept. 16$91Sep. 21 – Oct. 2Sept. 30$110Oct. 5-16Oct. 14$110Oct. 19-30Oct. 28$110Nov. 2-13Nov. 11$91Nov. 16-27Nov. 24$110Nov. 30- Dec. 11Dec. 9$110Dec. 14-18Jan. 4-8Jan. 6$110Jan. 11-22Jan. 20$110Jan. 25 – Feb. 5Feb. 3$110Feb. 8-19Feb. 17$110Feb. 22 – Mar. 5Mar. 3$110Mar. 8-19Mar 17.$110Mar. 22-26Apr. 5-9Apr. 7$110Apr. 12-23Apr. 21$110Apr. 26-30May 3-7May 5$110May 10-21Revised Fee ScheduleIf there are snow days added to the school calendar, you will not pay for those days since you paid for them prior in the year.Please Retain This Sheet for Your Records ................
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