The Excel Program Registration Form
The Excel Program Registration Form
Student Information
________________________ ______________________
Last Name First Name
__________ ______ ____/_____/_____ _____
Current Grade Age Birth date Sex
___________________________ ____________________________ _________________
Street Address City, State Zip Code
If registering for Excel Summer Program please list grade entering in the fall- _______
PARENT/GUARDIAN INFORMATION
Father: _________________________ Employer:__________________ Work Hours: __________
Home: ____________ Work: ____________ Cell: _____________
Email: _______________________________________________________________
Mother: ________________________ Employer:__________________ Work Hours: __________
Home: _____________ Work: ____________ Cell: ____________
Email: _______________________________________________________________
Guardian: _______________________ Employer:__________________ Work Hours: __________
Home: _____________ Work: ____________ Cell:_____________
Email: _______________________________________________________________
Person(s) Responsible for Payment:
Name(s) __________________________ Social Security Number(s) _________________________
Address(es) ____________________________________________
Student lives with (check all that apply): [ ] Father [ ] Mother [ ] Guardian
Is there a court order protecting the custody of this child? ___ Yes ___ No
If yes, a copy of the court order must be included with this registration.
EMERGENCY CONTACTS & Student Pick Up
In the event the parents/guardians cannot be reached, the school will call the people listed below. People listed should be individuals who can: 1) give permission to administer health care; 2) pick up your child if your child is ill; and 3) give advice about caring for your child. Please list people who you authorize to pick up your child(ren) from the Excel childcare program. (Must show identification when picking up)
Name: ________________________ Name: _______________________
Phone Number: _________________ Phone Number: __________________
Relationship to student: ___________ Relationship to student___________
HEALTH INFORMATION
Physician: _____________________________________ Phone: __________________________
Dentist: ______________________________________ Phone: __________________________
Medication(s) being take by student: ___________________________________________________________________
Physical conditions (allergies, diabetes, etc.): ___________________________________________________________________
If I, my child’s emergency contacts listed above, or the physician listed above, cannot be reached in an emergency, I authorize school employees or legal representatives to obtain emergency medical care for my child while under the school’s care including transporting or sending my child to an available hospital or physician.
Signature ____________________________________ Date: _________________
I authorize the Excel Program to administer Tylenol for minor aches such as a headache.
Signature ____________________________________ Date: _________________
Statement of Health
I do declare that the child named on this contract is in good health and is able to
participate in all activities offered by the Excel Program.
______________________________________________________________
#1 Parent/guardian signature Date
Parent Contract
I am enrolling ______________________________________ in the after school and/or summer program. Enrollment, which is on a first-come, first-served basis, is completed upon receipt of required forms including full payment (registration fee and 1 week’s fee). Tuition payments are due on Monday of each week, or monthly. Payments received after 6:00 p.m. on Fridays are considered late. Accounts 10 days past due will result in suspension from the program until balance is paid in full - this includes late pick-up fees. I understand that in the event of nonpayment, I am responsible for all costs of collection (A collection cost of 35% of the delinquent balance will be added to the delinquent balance for collections).
(Your signature indicates acceptance of all policies and regulations of the Excel Program)
___________________________________________________________
#2 Parent/guardian signature Date
θI have received the Excel Program Parents’ Handbook, the parent handbook has fully informed me about the policies and procedures of the Excel Program. Among other topics, I have now been informed about the policies and procedures of discipline; homework; the release of children; tuition, fees, and payment structure; and termination from the program. This handbook will serve as a quick reference source to answer questions on policies and procedures.
______________________________________________________________
#3 Parent/guardian signature Date
Permission
Name of child: _______________________________________
Photographs
θ Yes, I give permission for my child’s photograph to be taken for use by the Excel Program publications and for release to local newspapers.
θ No, I do not want my child to be photographed.
Videotaping
θ Yes, my child may participate in videotaping for recreational purposes only.
θ No, I do not want my child to be videotaped.
Blanket Permission for Walking Trips
θ Yes, I give my child permission to participate in walks around the school’s
campus.
θ No, I do not want my child to go on walks.
Field Trips
θ Yes, I give my child permission to participate in field trips off campus.
θ No, I do not want my child to go on field trips.
______________________________________________________________
#4 Parent/guardian Signature Date
θ Withdrawal Procedure- 2 week notice
Notification of withdrawal must be given in writing two weeks in advance. If notification is not given tuition is still required for the next two weeks whether your child attends or not.
θ Summer Program Vacation Week Procedure
During the summer program one vacation is given to students who enrolls for the entire summer program. Students who enroll after the program begins, or withdrawals before the summer program ends will not receive a vacation week. The directors must be notified at least two weeks prior to vacation dates in order for the students to receive credit for the week.
I have read ad understand Withdrawal and Vacation Procedures
______________________________________________________________
#5 Parent/guardian Signature Date
A completed registration includes:
⎫ Registration Form - an original registration form must be received.
⎫Payment must be included (Registration Fee and 1st Week’s Tuition).
⎫A copy of immunization
______________________________________________________________________________
After School Program
Check one:
_______Full-Time
______ Part Time Which days? Mon. Tues. Wed. Thurs. Fri. (circle)
______Enrichment Day Which day? Mon. Tues. Wed. Thurs. Fri. (circle)
______________________________________________________________
Summer Program
Check one:
_______Full-Time
______ Part Time Which days? Mon. Tues. Wed. Thurs. Fri. (circle)
____________________________________________________________
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Andrea White ~ Shannon Browning h5 @hWn5?CJOJQJ^J aJh5 @5?CJOJQJ^J aJhWnCJOJQJ^J aJhWnCJOJQJ^J aJhWn5?CJOJQJ^J aJhWnCJOJ QJ ^J aJ-hWnCJOJPJQJ^JaJhWnCJ HYPERLINK "mailto:excelprogram@" [pic]excelprogram@ 1-870-761-2029
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