AFTER SCHOOL CARE After-school-program-flyer-3 STUDENT GENERAL INFORMATION1st Child First Last 1st Child Age2nd Child First Last 2nd Child Age3rd Child First Last 3rd Child Age4th Child First Last 4th Child AgeAddress Street Address Township City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PARENT / GUARDIAN INFORMATIONMother's Full Name First Last Mother's Primary Phone:Mother's Alt Phone / Work:Mother's Email Address: Father's Full Name: First Last Father's PhoneFather's Alt Phone / Work:Father's Email Address: ALTERNATE EMERGENCY CONTACTS (3 REQUIRED)NOTICE: Students will ONLY be released to a parent, legal guardian, or an authorized alternate emergency contact person listed below. Proper photo identification is required upon pickup.Full Name(Required) First Last Relationship(Required)Phone(Required)Full Name(Required) First Last Relationship(Required)Phone(Required)Full Name(Required) First Last Relationship(Required)Phone(Required)STUDENT MEDICAL PROFILE & PHYSICIAN INFOPrimary Care Physician Name:Physician Phone / Clinic Number:Known Food / Environmental / Drug Allergies:Pertinent Health Information, Diagnoses, or Chronic Medical Conditions:Current Medications (Include dosage, timings, and school administration needs):Dietary Restrictions, Physical Activity Modifications, or Special Accommodations:PROGRAM POLICIES, COMPLIANCE DISCLOSURES & LEGAL AGREEMENTSPlease carefully review and acknowledge each individual policy framework below. Checking each box serves as an official legal validation of compliance, financial liability, and administrative awareness.Video Taping & Picture Taking (CONSENT): I understand and give my permission to Thomas Township and the Parks and Recreation Staff to video-tape, capture on camera, and use my child’s image on the website or in brochures for the use of Thomas Township’s Parks and Recreation. Information Changes Acknowledgement:(Required) I understand that it is my responsibility to notify staff of any changes in family and/or emergency information notated on the child information form. Children will not be released to someone not listed. Late Pick-Up Financial Policy:(Required) I understand that the After School Program closes each day at 5:30pm and a late pick up will incure a late fee of $10. Emergency Medical Treatment Agreement:(Required) Thomas Township and the Parks and Recreation Staff have my permission to seek medical treatment for my child, in the event that I cannot be reached for an medical emergency. I hereby give my permission to the physician selected by the Director to hospitalize, secure proper treatment for or order injections, anesthesia or surgery for my child as named on page 1 of the After School Program form. Credits / Refunds / Absences Policy:(Required) I understand that the weekly fee that is paid is based upon enrollment, not attendance. There are no refunds for absences/non-attendance. Credits may be given for weeks paid but not attended. No credits will be given for days not attended during the week. Schedules & Registration Payments:(Required) I understand that full trimester payment is due at the time of registration. Individual week registration payments for the first two weeks is due at the time of initial registration. After that, payment for the week is due each Thursday by 5:00pm Payments submitted late will incur a $25 late fee. Legal Attestation & Waiver:(Required) By signing below, I certify that all fields, emergency designations, and health conditions recorded on pages 1 and 2 of this registration form are verified as accurate. I accept full civic and personal accountability for compliance with the codified policies of Thomas Township Parks and Recreation. Please check box to indicate your After School Program choice/s. Add across each row and total down the last column to get total cost. Payments can be made in person at the Thomas Township Office via cash or check or by credit card at the Thomas Township website. Tuition Fee Schedule Registration Type Tuition 1st Child Resident (Full Trimester) $1,300 Each Additional Resident Child (Full Trimester) $1,170 1st Child Non-Resident (Full Trimester) $1,690 Each Additional Non-Resident Child (Full Trimester) $1,521 Registration Type Weekly Tuition 1st Child Resident $110/week Each Additional Resident Child $100/week per child 1st Child Non-Resident $140/week Each Additional Non-Resident Child $125/week per child Week Dates Program Information Week 5 Dec 21 – 25 CHRISTMAS VACATION Call office for special programming. 989-781-0151 Week 6 Dec 28 – Jan 1 CHRISTMAS VACATION Call office for special programming. 989-781-0151 ChildResident – 1st ChildResident – 2nd ChildResident – 3rd ChildResident – 4th ChildNon-Resident – 1st ChildNon-Resident – 2nd ChildNon-Resident – 3rd ChildNon-Resident – 4th ChildWeeks Attending FULL 2nd TRIMESTER; 15 weeks Nov 23 – Mar 5 Nov 23 – Nov 27 Nov 30 – Dec 4 Dec 7 – Dec 11 Dec 14 – Dec 18 Jan 4 – Jan 8 Jan 11 – Jan 15 Jan 18 – Jan 22 Jan 25 – Jan 29 Feb 1 – Feb 5 Feb 8 – Feb 12 Feb 15 – Feb 19 Feb 22 – Feb 26 Mar 1 – Mar 5 CLOSED Nov 26 & Nov 27 Wk 1 Dec 24 & Dec 25 Wk 5 Dec 31 & Jan 1 Wk 6ChildResident – 1st ChildResident – 2nd ChildResident – 3rd ChildResident – 4th ChildNon-Resident – 1st ChildNon-Resident – 2nd ChildNon-Resident – 3rd ChildNon-Resident – 4th ChildWeeks Attending FULL 2nd TRIMESTER; 15 weeks Nov 23 – Mar 5 Nov 23 – Nov 27 Nov 30 – Dec 4 Dec 7 – Dec 11 Dec 14 – Dec 18 Jan 4 – Jan 8 Jan 11 – Jan 15 Jan 18 – Jan 22 Jan 25 – Jan 29 Feb 1 – Feb 5 Feb 8 – Feb 12 Feb 15 – Feb 19 Feb 22 – Feb 26 Mar 1 – Mar 5 CLOSED Nov 26 & Nov 27 Wk 1 Dec 24 & Dec 25 Wk 5 Dec 31 & Jan 1 Wk 6ChildResident – 1st ChildResident – 2nd ChildResident – 3rd ChildResident – 4th ChildNon-Resident – 1st ChildNon-Resident – 2nd ChildNon-Resident – 3rd ChildNon-Resident – 4th ChildWeeks Attending FULL 2nd TRIMESTER; 15 weeks Nov 23 – Mar 5 Nov 23 – Nov 27 Nov 30 – Dec 4 Dec 7 – Dec 11 Dec 14 – Dec 18 Jan 4 – Jan 8 Jan 11 – Jan 15 Jan 18 – Jan 22 Jan 25 – Jan 29 Feb 1 – Feb 5 Feb 8 – Feb 12 Feb 15 – Feb 19 Feb 22 – Feb 26 Mar 1 – Mar 5 CLOSED Nov 26 & Nov 27 Wk 1 Dec 24 & Dec 25 Wk 5 Dec 31 & Jan 1 Wk 6ChildResident – 1st ChildResident – 2nd ChildResident – 3rd ChildResident – 4th ChildNon-Resident – 1st ChildNon-Resident – 2nd ChildNon-Resident – 3rd ChildNon-Resident – 4th ChildWeeks Attending FULL 2nd TRIMESTER; 15 weeks Nov 23 – Mar 5 Nov 23 – Nov 27 Nov 30 – Dec 4 Dec 7 – Dec 11 Dec 14 – Dec 18 Jan 4 – Jan 8 Jan 11 – Jan 15 Jan 18 – Jan 22 Jan 25 – Jan 29 Feb 1 – Feb 5 Feb 8 – Feb 12 Feb 15 – Feb 19 Feb 22 – Feb 26 Mar 1 – Mar 5 CLOSED Nov 26 & Nov 27 Wk 1 Dec 24 & Dec 25 Wk 5 Dec 31 & Jan 1 Wk 6BINDING AUTHORIZATION & SIGNATUREParent / Legal Guardian Printed Name:(Required)Date Signed:(Required) Authorized Parent / Guardian Signature:Your NameYour NameYour NameYour Name
