Before and After School Program Agreement - Griffin Foundation

Before and After School Program Agreement 2020-2021
Consent*
I agree
I agree to enroll my child, whose name is in the filed below, in the Griffin Foundation School District's Before and After School Program beginning on the date below.
Child Name*
Date*
MM
DD
YYYY
This program is designed to serve students ages 3 - 12. A student that has behavior issues such as not following classroom procedures, endangering the safety of other students, or showing disrespect will be suspended or placed on a 2 weeks probation period. I understand the school will provide my child with a quality program lead by caring staff in a safe and positive learning environment. Hours of operation: Monday through Friday 4:00 pm - 6:00 pm; except on Wednesday 3:00 pm -6:00 pm. A late pick-up charge of $1.00 per minute will be assessed by the agency if a child is not picked-up at the close of business. of business

Tuition and Fees

I understand,

1. My weekly tuition is the below amount, if applicable DES co-pay per week is below. Parent(s) are required to pay for their child's/children's services by the week before services are rendered, or at the latest, the first day of the week services are provided. If payment is not received by the due date, a $15 late fee will be charged each week on the past due balance. After two weeks of nonpayment, the child will be removed from the program until balance is paid in full (no exceptions). A child that is not picked-up one hour from the close of business, the school representative will contact DCS and/or the Police Department for child pick-up. A $1 per minute charge will be billed to your account.
Weekly Tuition*
DES co-pay
2. One week's tuition, to be submitted with your application, is held as a deposit. The first week's tuition will be used as advance payment for the first week of class.

3. A non-refundable $45.00 registration and processing fee is due at enrollment.

4. Payment is due for the contracted time, including statutory holidays, whether the child attends or not. Tuition will be waived for Fall Break (1 week), Winter Break (2 weeks), and Spring Break (1 week).

5. The school district will provide a thirty-day notice prior to a rate increase.

6. I have the option to enroll my child in extra-curricular activities for an extra charge.

7. Mandatory withdrawal will be requested if a child does not abide by the standards of conduct, demonstrates extreme behaviors that hurt others or failure of the school to meet the needs of the child or parents.

8. Any checks not honored by the bank will be subject to a $30.00 service charge
Registration

9. Parents will complete all registration forms including; health records, emergency and permission authorizations for pick-up and any other required records or forms before student entry into the program.

10. Parents agree to bring their child/children to the program on time and pick him/her up on time after program ends.

11. To pick-up their child on time before the close of business.

12. If you attempted to call the main office during before or after school hours, and no answer, you can try calling the Before and After School Program directly at 790-8400 ext. 2034.

13. The Before and After School Program will be closed for Labor Day, Veteran's Day, Thanksgiving Day, Christmas Day, New Year's Day, Martin Luther King Day, Rodeo Break, Memorial Day, and 4th of July; as well as one week for Spring Break, Fall Break, and two weeks for Winter Break (refer to school calendar). We may include other closures; parents/guardians will be notified in advance.

14. The district will be closed in the case of extreme weather conditions (i.e. heavy snow or storm causing power outages).

15. By signing this document you agree and understand the policies and procedures of the Before and After School Program:

Parent/ Guardian Consent*
As the Parent or Guardian
I consent, acknowledge, and approve of the procedures, rules, and regulations of the Griffin Foundation School District's Before and After School Program.
Arizona Department of Health Services: The licensing agency shall have the authority to interview children or staff and to inspect child and facility records without prior consent. The licensing agency shall also have the authority to observe the physical condition of children, which could indicate possible abuse or neglect.
I authorize the school district to call an emergency ambulance in case of accident or acute illness and to arrange for possible emergency medical and surgical care in case I am not immediately available. Before such action is taken, it is understood that a conscientious effort must be made to notify me or the below contact at the following number:
Secondary Emergency Contact Name
Phone
Before and After School Schedule (Select days):
Full Name*
Home Phone*
Work/Cell Phone
Signature

Arizona Department of Health Services Bureau of Child Care Licensing Emergency, Information and Immunization Record Card
Child's Name*
Enrollment Date*
MM
DD
YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Date of Birth*
Date Format: MM slash DD slash YYYY
Sex:*
- Male
- Female
Parent or Guardian Name*
Address*
Street Address Address Line 2 City State ZIP Code
Contact Telephone Number*
Cell Phone (Optional)
Parent or Guardian Name
Address
Street Address Address Line 2 City State ZIP Code
Contact Telephone Number
Cell Phone (Optional)
I authorize the following individuals to collect my child from the facility in case of emergency or if I cannot be contacted: (Pursuant to R9-5-304.B, at least two contact persons are required.)
Name*
Contact Telephone Number*
Name*
Contact Telephone Number*
Name
Contact Telephone Number
Name
Contact Telephone Number
If Medical care is necessary, call the below *Healthcare Provider:
Name
Contact Telephone Number
*A Health Care Provider is a physician, physician assistant or registered nurse practitioner.
In case of injury or sudden illness, I request that this individual be called first:
Name
The following individual(s) may NOT remove my child from the facility:
Name(s):
Custody papers have been provided and are on file at the facility.
- Yes
- No
Telephone Authorization Code (optional):

Step 1 of 5

Tuition and Fees

Registration

Arizona Department of Health Services Bureau of Child Care Licensing Emergency, Information and Immunization Record Card

In case of injury or sudden illness, I request that this individual be called first:

Immunization Information

Section Break

Medical Information