WALNUT BEND ELEMENTARY SCHOOLWALNUT BEND ELEMENTARY SCHOOL

“EAGLE ’ S NEST “ “EAGLE ’ S NEST “ AFTER SCHOOL PROGRAMAFTER SCHOOL PROGRAM

REGISTRATION GUIDE Fa l l 2015REGISTRATION GUIDE Fa l l 2015 Download complete Registration Packet from http://www.houstonisd.org/domain/22213

(Enrichment Class Descriptions are NOT included in this printed packet. You may download them from the website. Thank you.)

NOTE: On Site Registration will also be held on Tool-UP Night held before school begins.

Questions: Contact Sylvia Ponce de Leon, Director: ciasp2@sbcglobal.net OR 713-529-3507 Contact Diana Alcebo, Coordinator: wbeaglesnest@yahoo.com or 713-917-3540

Registration Info Dates Where On Site Early Registration

August 17 – 21 Until 3:30

August 24 – 28 Until 6:30

Eagle’s Nest Office

*On-Site Tool-UP Registration 9:00-11:00 AM AN 5:00-7:00 PM

Friday, August 14 Eagle’s Nest Office

Late Registration (Registration is first come first serve. Late Registration Fee of $15.00 is to be included in your payment.)

After August 31 Eagle’s Nest Office

Add-Drop Deadline September 11 Eagle’s Nest Office Extended Day Aug. 24 – Dec. 18 On Site Homework Classes Sept. 1 – Dec. 19 On Site

Ext Day Payment Options: $50.00 OR $58 Weekly OR 5 payments on 1st Friday of each month: 1st Pymt: At Registration; 2nd Pymt: Sept. 4; 3rd Pymt: Oct. 2; 4th Pymt: Nov. 6; 5th Pymt: Dec. 4

Final Payment (Dec. 4) must be submitted in the form of a Money Order.

Make your money order OR check payable to: Walnut Bend Elementary

Creativity

Discipline/ self esteem

Sportsmanship

Recycle

Body movement Eco-friendly

Copyright © 2015 c.h.i.l.d.r.e.n.s. Initiatives After School Programs Parent Copy

Your registration packet is complete when it includes the following items for each child:

______Extended Day and Enrichment Options (Page 4) ______Contract Agreement/Safety Plan Form - signed] (Page 5)

______Authorization Form (Page 6) ______Tuition Fee Form (Page 7) ONLY for NEW Enrollments ______A check or money order payable to: Walnut Bend Elementary

Dear Walnut Bend Parents, Walnut Bend Elementary is proud to present a quality After School Program. This program is designed to provide the needs of the school community in an after school setting. The quality of our program will thrive with the cooperation of the school community (i.e. administration, staff, parents, children).

This packet is comprised of several forms. We ask that you review each form and submit only those that apply to your particular registration. To better assist you, please note the documents included in this packet:

Enclosed in this packet are the following forms: • Page 1 Front Cover Page with Deadlines (PARENT COPY) • Page 2 Parent Letter (PARENT COPY) • Page 3 Contract Agreement/Safety Plan (PARENT COPY) • Page 4 Extended Day Options (OFFICE COPY) • Page 5 Contract Agreement/Safety Plan (OFFICE COPY) • Page 6 Authorization/Emergency Form (OFFICE COPY) • Page 7 Tuition Fee Form (OFFICE COPY) ONLY FOR NEW ENROLLMENTS

IMPORTANT INFORMATION FOR YOU TO KNOW:

1. REGISTRATION: Registrations are processed as they are received. The date and/or order of registration submission will be recorded on your paperwork.

• Beginning August 14: Registration forms will be available to be submitted to the After School Office at Walnut Bend Elementary by Friday August 14.

• Registrations received after August 21 will be processed for services to begin 2 days after the 1st day of school (Aug. 24).

2. OUTSTANDING BALANCES: Registration cannot be accepted from anyone who has an outstanding balance from any previous semester. Registrations submitted must include a separate check for their outstanding balance in addition to their first payment. Any accounts with outstanding balances over $100.00 remaining after December 19 will be assessed a $25.00 collection fee, which will be rolled over to the Spring 2016 semester. Failure to meet your financial obligations may result in suspension of services to you. In addition, at the end of the Spring 2016 Semester any account with outstanding balances over $100.00 will be assessed a $25.00 collection fee, which will be rolled over to the Fall 2016 semester.

3. PAYMENT: All checks/money orders are to be made payable to: Walnut Bend Elementary. You may either submit your payment of the full amount of your bill at the time of registration OR you may submit your payments in 5 installments, OR you may submit weekly payments. The Final Payment must be submitted in the form of a Money Order. This is offered as a convenience to you. Please see the Contract Agreement Safety Plan Form for important details including deadlines.

4. RETURNED CHECKS: Checks returned by the bank must be repaid in the form of a money order for the exact amount. In addition, there is a check return fee of $35.00 that must be submitted in a separate money order. Failure to do this within 24 hours of notification may result in suspension of services.

We are looking forward to a successful Fall 2015 Semester! If you have any other concerns and/or questions, please do not hesitate to contact either one of us below.

Sincerely,

Sylvia Ponce de Leon Director, After-School Programs 713-529-3507 Email: ciasp2@sbcglobal.net Parent copy 2

Copyright 2015 © childrens initiatives After School Programs

W A L N U T B E N D E L E M E N T A R YW A L N U T B E N D E L E M E N T A R Y

EAGLE ’S NEST AFTER SCHOOL PROGRAMEAGLE ’S NEST AFTER SCHOOL PROGRAM

Cont ract Agreement/Safety P l an Cont ract Agreement/Safety P l an FALL 2015FALL 2015

By initialing and signing below, I understand the contents of this registration packet and agree to the following for the Fall Semester of 2015. Disregard of this contract and/or the contents in the registration packet will result in immediate dismissal from Eagle’s Nest After School Program. 1. REGISTRATION: Registration in Extended Day Program (Aug. 24-Dec. 18) is for the entire Fall Session. COSTS are not prorated after the Add/Drop

deadline of SEPT. 11. Only 2 changes are permitted during the semester. 3 or more changes will incur a fee of $15.00 each time. All registered students will receive confirmation via a statement the week of Aug. 24 at the time of pick up. if you submitted your registration by Aug. 21. No class changes will be made and no refunds or credits will be issued after Sept. 11. However, any weeks attended during the weeks of Aug. 24-Sept. 11 will be prorated. I understand that my registration is ONLY valid if I have paid out all prior balances owed to Walnut Bend After School Program. Furthermore, I understand that if I submit my registration after August 31, I will be assessed a Late Registration Fee of $15.00. In addition, if I submit my registration after Aug. 21 my registration will be processed for services to begin within 2 school days. Furthermore, I must make other arrangements for After School until my child’s registration has been processed. In addition, NO refunds will be assessed in the event of HISD canceling after-school activities for inclement weather or any other extenuating circumstances.

2. SIGN OUT: I will sign out my child from an After School Staff Member each day. If my child is enrolled ONLY in Enrichment Classes, I will sign out my child from an After School Staff Member located in the front office at the time the Enrichment Class ends. SHOWING PHOTO ID IS MANDATORY UPON REQUEST.

3. LATE PICK UP: • If my child is enrolled in Full Time Extended Day and is picked up after 6:00 PM I understand I will be assessed a late pickup fee of $2.00/ per minute. • If my child is enrolled in Full Time Extended Day Plus, and is picked up after 6:30 I will be assessed a late pickup fee of $2.00/per minute. • If my child has Occasional Units and the child is picked up after 6:00 I will be assessed a late pickup fee of $2.00/ per minute. • If my child has Occasional Units Plus and the child is picked up after 6:30 I will be assessed a late pickup fee of $2.00/ per minute. • If my child is enrolled ONLY IN AN ENRICHMENT CLASS AND I am late picking up my child by the end of class time, I understand I may be assessed a late pick up fee of $2.00/minute. If I am late more than 6 minutes, I have the option of purchasing Half-Time Occ Extended Day of 5-Units which will provide supervision until 6:00 PM. 1 Unit from this card will be used for the late pick up of the day I purchase this option and I understand that I will have 4 Units remaining. After 6:00 PM, I will be assessed a fee of $2.00/minute. • After the 5th late pick-up I may be asked to make other arrangements for After School Child Care. • The official time for our after school program will be gauged by the clock located in the school office. • Please Note: If late pick-up fees are not paid within 24 hours, the fee is automatically doubled (Check or money order only)

4. EXT DAY: I understand the hours of Extended Day are: Full Time Extended Day 2:45-6:00 p.m.; Full Time Extended Day Plus 2:45-6:30 pm.; Occasional Extended Day 2:45-6:00 p.m.; Occasional Extended Day Plus 2:45-6:00 p.m.

5. OCCASIONAL and OCCASIONAL PLUS DAYS: • If I no longer have any Occasional Extended Day Units OR Occasional Extended Day Plus Units remaining, another 5-Unit Card will be AUTOMATICALLY billed to my account. • I understand that any Occasional Extended Day Units OR Occasional Extended Day Plus Unit purchases billed after May 3 MUST BE PAID WITHIN

IN 24 HOURS OR THERE WILL BE NO SERVICES PROVIDED. 6. PICK UP CHANGES/NOTIFICATIONS: I am aware that my child MUST be picked up by an adult and that my child will never be allowed to walk home without

the supervision of an authorized adult I have listed on the Authorization Contact Form. Furthermore, I will notify in writing via a handwritten note or via email, the Director (ciasp2@sbcglobal.net) and or Coordinator (dalcebo@houstonisd.org), when my child will not report to Extended Day for any of the following reasons: A. I will be picking up my child before OR at 2:45 p.m. B. Someone else, authorized by me, will pick up my child @ 2:45 p.m.

7. PAYMENTS: ____MUST BE SUBMITTED BY CHECK OR MONEY ORDER ONLY made out to Walnut Bend Elementary. The Final Payment due by Dec. 4 must be paid in the form of a money order. Cash is not accepted. ____If I select to pay biweekly, I will submit my first biweekly payment at the time of registration. The next biweekly payment will be due by Sept. 4. All subsequent biweekly payments will be set up by the after school Coordinator at the sign out desk located in the cafeteria. ____If I select to pay in 5 installments I will pay at least of 1/5 of my total balance at the time of registration. The next 4 payments are due as follows: Sept. 4; Oct. 4; Nov. 6; Dec. 4. ____If I do not submit my payments by the due dates, I will be assessed a late fee of $10.00 on the next day the payment was due. ____I will be assessed a $35.00 charge for each returned check. All returned checks must be repaid to the school within 24 hours after being notified via a Money Order for the EXACT amount of the returned check. In addition, there is a $35.00 check return fee assessed by HISD. This payment must be submitted in a separate money order on the same day you submit the money order for the returned check. After 1 returned check, all future payments must be made by money order. *** ____I understand that after school services will be suspended if I do not pay my bill on time.

8. BEHAVIOR EXPECTATIONS: The HISD Code of Student Conduct will serve as the basis for all discipline expectations to ensure the safety of all students and staff members. Parents will be notified immediately if their child has violated any portion of the school’s previously communicated Code of Student Conduct. Services will be suspended should disrespectful or unsafe behavior be directed towards a student or staff member, either by a parent of a student or a student enrolled in the program. I understand that it is my responsibility for reading and knowing the expectations of the HISD Code of Conduct. I also understand that the program reserves the right to deny services on a permanent basis if behavior expectations are not being met.

9. SPECIAL NEEDS: We do not provide staff trained to deal with special needs. Please contact the ASP Coordinator regarding any questions. 10. Contact Info: I understand that my email address and/or phone number(s) may be given to the Provider of any Enrichment class in which I have enrolled my

child should the Provider find it necessary to contact me for After School Activities ONLY. 11. Technology DEVICES: While students during the school day may be permitted to use their technology during the school day under the supervision of their teacher, no technology devices may be used in the after school program by any student in grades PK-5. All such devices must be kept in the student’s backpack. 12. Disregard of any portion of this contract calls for immediate dismissal from the After School Program. By signing this contract, I

am agreeing to all of the above terms and fully understand all information listed on the Parent Letter AND on any of the forms of this packet

_______________________________________/_____________________________________/_______________ _________________________________ Name of Parent (please print) Parent Signature Date STUDENT NAME

_______________________________________/_____________________________________/_______________ _________________________________ Name of Parent (please print) Parent Signature Date STUDENT NAME

Parent Copy 3 Copyright ! 2015 c.h.i.l.d.r.e.n.s. Initiatives After School Programs

W A L N U T B E N W A L N U T B E N D E L E M E N T A R Y D E L E M E N T A R Y

““ E A G L E ’ S N E S T ” A F T E R S C H O O L P R O G R A M E A G L E ’ S N E S T ” A F T E R S C H O O L P R O G R A M

E X TE N D E D D AY O PT I O N S & TU I TI O N / F E E F O R M E X TE N D E D D AY O PT I O N S & T U I T I O N / FE E F O R M -- FAL L 2 0 1 5FAL L 2 0 1 5

_______________________________________________________/____________________________________/__________________ STUDENTʼS NAME HR Teacher (2015-2016) GRADE ______________________________________________________________________________________________________________ PARENT/GUARDIANʼS NAME(S) RESPONSIBLE FOR BILLING ______________________________________________________________________________________________________________ BILLING ADDRESS (INCLUDING ZIP CODE) ________________________________________________________ ______________________________/_____________________________ Email Address(es) HOME PHONE WORK PHONE (___________)________________-____________________ (___________)________________-______________________ Mom’s Cell Phone Dad’s Cell Phone

Walnut Bend Elementary Eagle’s Nest Total Cost

A. Grand Total of Extended Day (Full Time OR Occasional) $ _______________ (A)

B. Total for Homework Enrichment (This line is only if you are enrolled in Homework Enr ONLY) $ _______________ (B)

C. Grand Total of A, B (Ext Day, Homework ENR) $ _______________ (C)

D. Payment Enclosed (must be minimum weekly cost of Ext Day) $ _______________ (D) (Please pay Occasional Extended Days in Full)

Parentʼs Signature__________________________________________________________Date_______________________________________________

For Office Use Only Date Amount Check # Initial Payment At Registration _________________________________________________________________________________

NOTE: When your child is not attending a Homework Class, he/she will be under the supervision of an Extended Day Group Leader working on different planned activities. Thank you.

Copyright ! 2015 c.h.i.l.d.r.e.n.s. Initiatives After School Programs

EXTENDED DAY OPTIONS Occasional Extended Day Ext Day Program

" Select One

"5 Units

"10 Units

"15 Units

"20 Units

"25 Units

Full Time Ext Day/$50/WK (2:45-6:00)

$820 OR $60 $120 $180 $240 $300

Full Time Ext Day Plus/$58/WK (2:45-6:30)

$955 OR $70 $130 $190 $250 $310

Early Dismissal per Day (12:30-2:45)

$12

Homework Ext Day – All students enrolled in Ext Day will be allotted a maximum of 1 hour of Homework Time Daily. Homework Enrichment – This is for the student who is not enrolled in any part of Ext day. Homework Enrichment (3:15-4:15) $115/day Circle

day(s) Mon Tues Wed Thur Fri

Initial those that

apply to you

Acceptance of ATB Walnut Bend Contract

Submitting Full payment (Grand total – Line E)

Paying 1/5 of GRAND TOTAL Paying Different amount (AT LEAST WEEKLY COST OF EXT DAY AND/OR FULL COST OF OCC)

Please initial Total Pymt Please initial Total Pymt Please initial Total Pymt Please initial

$ $ $

4 Office Copy

W A L N U T B E N D E L E M E N T A R YW A L N U T B E N D E L E M E N T A R Y

EAGLE ’S NEST AFTER SCHOOL PROGRAMEAGLE ’S NEST AFTER SCHOOL PROGRAM

Cont ract Agreement/Safety P l an Cont ract Agreement/Safety P l an FALL 2015FALL 2015

By initialing and signing below, I understand the contents of this registration packet and agree to the following for the Fall Semester of 2015. Disregard of this contract and/or the contents in the registration packet will result in immediate dismissal from Eagle’s Nest After School Program. 1. REGISTRATION: Registration in Extended Day Program (Aug. 24-Dec. 18) is for the entire Fall Session. COSTS are not prorated after the Add/Drop

deadline of SEPT. 11. Only 2 changes are permitted during the semester. 3 or more changes will incur a fee of $15.00 each time. All registered students will receive confirmation via a statement the week of Aug. 24 at the time of pick up. if you submitted your registration by Aug. 21. No class changes will be made and no refunds or credits will be issued after Sept. 11. However, any weeks attended during the weeks of Aug. 24-Sept. 11 will be prorated. I understand that my registration is ONLY valid if I have paid out all prior balances owed to Walnut Bend After School Program. Furthermore, I understand that if I submit my registration after August 31, I will be assessed a Late Registration Fee of $15.00. In addition, if I submit my registration after Aug. 21 my registration will be processed for services to begin within 2 school days. Furthermore, I must make other arrangements for After School until my child’s registration has been processed. In addition, NO refunds will be assessed in the event of HISD canceling after-school activities for inclement weather or any other extenuating circumstances.

2. SIGN OUT: I will sign out my child from an After School Staff Member each day. If my child is enrolled ONLY in Enrichment Classes, I will sign out my child from an After School Staff Member located in the front office at the time the Enrichment Class ends. SHOWING PHOTO ID IS MANDATORY UPON REQUEST.

3. LATE PICK UP: • If my child is enrolled in Full Time Extended Day and is picked up after 6:00 PM I understand I will be assessed a late pickup fee of $2.00/ per minute. • If my child is enrolled in Full Time Extended Day Plus, and is picked up after 6:30 I will be assessed a late pickup fee of $2.00/per minute. • If my child has Occasional Units and the child is picked up after 6:00 I will be assessed a late pickup fee of $2.00/ per minute. • If my child has Occasional Units Plus and the child is picked up after 6:30 I will be assessed a late pickup fee of $2.00/ per minute. • If my child is enrolled ONLY IN AN ENRICHMENT CLASS AND I am late picking up my child by the end of class time, I understand I may be assessed a late pick up fee of $2.00/minute. If I am late more than 6 minutes, I have the option of purchasing Half-Time Occ Extended Day of 5-Units which will provide supervision until 6:00 PM. 1 Unit from this card will be used for the late pick up of the day I purchase this option and I understand that I will have 4 Units remaining. After 6:00 PM, I will be assessed a fee of $2.00/minute. • After the 5th late pick-up I may be asked to make other arrangements for After School Child Care. • The official time for our after school program will be gauged by the clock located in the school office. • Please Note: If late pick-up fees are not paid within 24 hours, the fee is automatically doubled (Check or money order only)

4. EXT DAY: I understand the hours of Extended Day are: Full Time Extended Day 2:45-6:00 p.m.; Full Time Extended Day Plus 2:45-6:30 pm.; Occasional Extended Day 2:45-6:00 p.m.; Occasional Extended Day Plus 2:45-6:00 p.m.

5. OCCASIONAL and OCCASIONAL PLUS DAYS: • If I no longer have any Occasional Extended Day Units OR Occasional Extended Day Plus Units remaining, another 5-Unit Card will be AUTOMATICALLY billed to my account. • I understand that any Occasional Extended Day Units OR Occasional Extended Day Plus Unit purchases billed after May 3 MUST BE PAID WITHIN

IN 24 HOURS OR THERE WILL BE NO SERVICES PROVIDED. 6. PICK UP CHANGES/NOTIFICATIONS: I am aware that my child MUST be picked up by an adult and that my child will never be allowed to walk home without

the supervision of an authorized adult I have listed on the Authorization Contact Form. Furthermore, I will notify in writing via a handwritten note or via email, the Director (ciasp2@sbcglobal.net) and or Coordinator (dalcebo@houstonisd.org), when my child will not report to Extended Day for any of the following reasons: A. I will be picking up my child before OR at 2:45 p.m. B. Someone else, authorized by me, will pick up my child @ 2:45 p.m.

7. PAYMENTS: ____MUST BE SUBMITTED BY CHECK OR MONEY ORDER ONLY made out to Walnut Bend Elementary. The Final Payment due by Dec. 4 must be paid in the form of a money order. Cash is not accepted. ____If I select to pay biweekly, I will submit my first biweekly payment at the time of registration. The next biweekly payment will be due by Sept. 4. All subsequent biweekly payments will be set up by the after school Coordinator at the sign out desk located in the cafeteria. ____If I select to pay in 5 installments I will pay at least of 1/5 of my total balance at the time of registration. The next 4 payments are due as follows: Sept. 4; Oct. 4; Nov. 6; Dec. 4. ____If I do not submit my payments by the due dates, I will be assessed a late fee of $10.00 on the next day the payment was due. ____I will be assessed a $35.00 charge for each returned check. All returned checks must be repaid to the school within 24 hours after being notified via a Money Order for the EXACT amount of the returned check. In addition, there is a $35.00 check return fee assessed by HISD. This payment must be submitted in a separate money order on the same day you submit the money order for the returned check. After 1 returned check, all future payments must be made by money order. *** ____I understand that after school services will be suspended if I do not pay my bill on time.

8. BEHAVIOR EXPECTATIONS: The HISD Code of Student Conduct will serve as the basis for all discipline expectations to ensure the safety of all students and staff members. Parents will be notified immediately if their child has violated any portion of the school’s previously communicated Code of Student Conduct. Services will be suspended should disrespectful or unsafe behavior be directed towards a student or staff member, either by a parent of a student or a student enrolled in the program. I understand that it is my responsibility for reading and knowing the expectations of the HISD Code of Conduct. I also understand that the program reserves the right to deny services on a permanent basis if behavior expectations are not being met.

9. SPECIAL NEEDS: We do not provide staff trained to deal with special needs. Please contact the ASP Coordinator regarding any questions. 10. Contact Info: I understand that my email address and/or phone number(s) may be given to the Provider of any Enrichment class in which I have enrolled my

child should the Provider find it necessary to contact me for After School Activities ONLY. 11. Technology DEVICES: While students during the school day may be permitted to use their technology during the school day under the supervision of their teacher, no technology devices may be used in the after school program by any student in grades PK-5. All such devices must be kept in the student’s backpack. 12. Disregard of any portion of this contract calls for immediate dismissal from the After School Program. By signing this contract, I

am agreeing to all of the above terms and fully understand all information listed on the Parent Letter AND on any of the forms of this packet

_______________________________________/_____________________________________/_______________ _________________________________ Name of Parent (please print) Parent Signature Date STUDENT NAME

_______________________________________/_____________________________________/_______________ _________________________________ Name of Parent (please print) Parent Signature Date STUDENT NAME

Office Copy 5 Copyright ! 2015 c.h.i.l.d.r.e.n.s. Initiatives After School Programs

W A L N U T B E N D E L E M E N T A R Y W A L N U T B E N D E L E M E N T A R Y

“E A G L E ’ S N E S T ” “E A G L E ’ S N E S T ”

A F T E R S C H O O L P R O G R A M A F T E R S C H O O L P R O G R A M

A U T H O R I Z A T I O N F O R M / A U T H O R I Z A T I O N F O R M / F A L L 2015F A L L 2015

_______________________________________/_____________________________________ Student’s Name HR Teacher 2015-2016 ______________________________/______________________________________________ Parent’s Name Contact Phone(s) # (i.e. cell, work, etc.) between 2:45-6:30PM _________________________/___________________________________________________ Parent’s Name Contact Phone(s) # (i.e. cell, work, etc.) between 2:45-6:30PM

Please list individuals authorized to pick up your child (other than yourself). We need individuals who can be here quickly in cases of: emergencies, traffic, illness, etc. Consider persons who are near the school such as neighbors, parents of classmates or the like. _____________________________________________________________________________

Name Work Phone # Home Phone# Other Phone#

_____________________________________________________________________________ Name Work Phone# Home Phone# Other Phone#

_____________________________________________________________________________

Name Work Phone# Home Phone# Other Phone# _____________________________________________________________________________

Name Work Phone# Home Phone# Other Phone# Allergies______________________________________________________________________ Please note the following: 1. It is important you notify the Eagle’s Nest in writing when you have updated information such as an address

change, phone change, and which individuals you authorize to pick up your child, foods your child may be allergic to, etc.

2. If you are unable to pick up your child for any reason, The Walnut Bend Eagle’s Nest will call an adult you have listed on this form.

3. DO NOT assume the school's front office relays changes you submit to them to the Eagle’s Nest Office. 4. On any given day you are having someone NOT listed on the Eagle’s Nest Authorization/Emergency Form pickup

your child, the Eagle’s Nest Office must receive notification in writing (no later than 1:00PM) from the parent or the individual registering the student. You MUST notify the Eagle’s Nest Office as follows:

A. Email this notification to: ciasp2@sbcglobal.net OR DALCEBO@houstonisd.org B. Fax it to: 713-917-3656 and address the note to the attention of Eagle’s Nest.

C. Drop off a note in the Eagle’s Nest Box located in the front school office. D. Drop off a note in the Eagle’s Nest Office.

5. Please be aware that we will NOT release your child to anyone unless we have it in writing. We cannot make any exceptions. It is your responsibility to update any information you provide on this form. Therefore, it is vital to plan ahead. In addition, your child WILL NOT be released to anyone who is under the age of 18. _____________________________________________________________________________ Parent Signature Date Copyright © 2015 c.h.i.l.d.r.e.n.s. Initiatives After School Programs

6

Office Copy

WALNUT BEND ELEMENTARY WALNUT BEND ELEMENTARY

“EAGLE ’ S NEST ”“EAGLE ’ S NEST ”

AFTER SCHOOL PROGRAMAFTER SCHOOL PROGRAM

TUITION/FEE FORM: FALL 2015TUITION/FEE FORM: FALL 2015

________________________________________________/____________________________________/__________________/ STUDENTʼS NAME HR Teacher (2015-2016) GRADE _______________________________________________________________________________________________________ PARENT/GUARDIANʼS NAME(S) RESPONSIBLE FOR BILLING _______________________________________________________________________________________________________ BILLING ADDRESS (INCLUDING ZIP CODE) ________________________________________________________ __________________________/__________________________ Email Address(es) HOME PHONE WORK PHONE (___________)________________-_________________ (___________)________________-_________________ Momʼs Cell Phone Dadʼs Cell Phone

Walnut Bend Eagle’s Nest Total Cost A. Grand Total of Extended Day (Full Time, Full Time Plus OR Occasional) $ _______________ (A) B. Total for Homework Enrichment $ _______________ (B) C. Grand Total of A, B $ _______________ (C) (Ext Day, Homework) D. Payment Enclosed (must be at least 1/5 of Grand Total) $ _______________ (D) (Please pay Occasional Extended Days in Full)

Name:________________________________Signature______________________________________Date______________ For Office Use Only Date Amount Check # Initial

Payment At Registration _______________________________________________________________________ Office Copy

Copyright © 2015 c.h.i.l.d.r.e.n.s. Initiatives After School Programs

Initial those that

apply to you Acceptance of

ATB Walnut Bend Contract

Submitting Full payment

Paying 1/4 of tuition

Paying Different amount

l

7 77