Registration Package
Parent’s Handbook General Registration Form Student’s Health Record Student’s Contract Method of Payment for Registration and Monthly Fees Agreements
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General Registration Form Student’s Name: (First)
(Last)
Address: M
F
Postal Code: Birth Date:
/
/
Grade:
(Day) (Month) (Year)
First Parent/Guardian Information
Relationship to the student:
Surname:
Given Name:
Address:
Postal Code:
Phone #: (c)
(w)
(h)
Email Address:
Second Parent/Guardian Information
Relationship to the student:
Surname:
Given Name:
Address:
Postal Code:
Phone #: (c)
(w)
(h)
Email Address:
Custody Information Are there any special custody arrangements pertaining to access to/visitation of your child? If you answered “yes” to the above, please provide details on the arrangements:
Copy of Custody Order provided:
Yes 2
Yes
No
EMERGENCY CONTACTS/PERSONS TO WHOM THE CHILD MAY BE RELEASED IN ADDITION TO PARENTS/GUARDIANS: Emergency Contact #1 Name: Relationship to the student: Phone #: (c)
(w)
(h)
(w)
(h)
(w)
(h)
Email Address:
Emergency Contact #2 Name: Relationship to the student: Phone #: (c) Email Address:
Emergency Contact #3 Name: Relationship to the student: Phone #: (c) Email Address:
Authorized Pick Ups (In addition to the Guardians and Emergency Contacts, must be 16 years of age or older; must sign child out at departure): Name:
Relationship to the student:
Name:
Relationship to the student:
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Student Health Record Student’s Name:
Date:
Alberta Health Care Number: Doctor/Medical Information: Doctor’s Name:
Phone #:
Address:
Postal Code:
Any dietary restrictions? Yes
No
If “yes” please include details below:
Are there any physical or other problems that we should be aware of that may interfere with the student’s full participation in the program or which may require special attention? Yes No If “yes” please include details below:
Allergies: Please list any allergies below: Allergy
Mild
Moderate
Severe
Life Threatening
If there is a life threatening allergy please describe below. Please also review this with the program director, prior to the start of the program:
Medical Conditions: If your child has asthma or any other medical condition such as epilepsy, haemophilia, diabetes or reactions to drugs which could be a complicating factor, please note this below:
Medications: Please list all medications, if any, which may need to be taken during the After School Program hours:
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Student’s Contract
My name is
. I will try my best to follow the rules listed below so I can have fun and be safe at the F.A.M.E. After School centre.
1. I will respect other students by using my words and not violence to explain how I feel about how they are treating me. 2. I will be caring to other students by helping them when they ask me for help or when they are sad and need a friend. I will also try to help the instructors when they ask me to help them. 3. I will be responsible, by looking after my belongings and F.A.M.E. After School’s equipment, by being gentle while playing and by cleaning up after each class. 4. I will try to be honest with other students and the instructors. 5. I will try to include other students whenever possible. 6. I will try to have FUN!!
Student’s Printed Name
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Method of Payment for Registration and Monthly Fees $40 Registration Fee (Please indicate your Method of Payment for the Registration Fee – non refundable, due at time of registration)
Visa/MasterCard
Cheque
$495 Monthly Fees st
(Please indicate your Method of Payment for the Monthly Program Fees, due at the 1 of the month)
Visa/MasterCard
Cheque
Pre-Authorized Debit/Void Cheque Have you attached a VOID Cheque? Account Type: Chequing
Yes
Savings
Account Holder Name: Account Holder Signature: By signing the above, you authorize F.A.M.E After School to charge the account identified above for payments according to the registration information provided.
Credit Card (Visa/MasterCard) Your credit card number will only be recorded in our software while you are registered at F.A.M.E. After School. Please indicate the Credit Card you wish to be debited for F.A.M.E. After School services. By signing the below, you authorize F.A.M.E. After School to charge the Credit Card identified below for payments according to the registration information provided. Name on Card:
Signature:
Address:
Postal Code:
Card #:
Expiry:
/
/
CCV:
*No refunds are given for days absent or statutory holidays. *Any payment that is returned as an NSF will be re-processed by the Bank within 10 business days. A $35.00 fee will apply to all returned payments. 6
AGREEMENTS (Please check the following) The parent/guardian agrees to comply with the centre’s policies, as stated in the Parent’s Handbook and all the above forms in the Registration Package. The parent/guardian has read and understood the Parent’s Handbook, available on the F.A.M.E. After School website: www.fameafterschool.com/ The parent/guardian understands that a one month (30 day) notice to withdraw from the program is required. A written request must be sent, on or before the first of the month, to the program director at fameafterschool@gmail.com to process the withdrawal. In case of emergency, and the parent/guardian is not able to be reached, the parent/guardian grants permission for the treatment of their child by a physician. The parent/guardian hereby consents to the collection, use and disclosure of their child’s information by the centre. I/we understand that the centre protects the privacy of all personal information in its possession, in compliance with the privacy legislation. Should any of the information provided change, I/we will inform F.A.M.E. After School immediately. The parent/guardian has read the Permission for Indirect Supervision section in the Parent Handbook, and hereby grants permission for their child to be indirectly supervised in such circumstances. (Optional) The parent/guardian gives permission for their child to be photographed or videotaped, and will be informed ahead of time of the purpose of the photographs and video. The parent/guardian understands and agrees that F.A.M.E. After School and/or it’s instructors will not be held responsible in any way for personal injury or loss of any personal belongings. As the parent/guardian, I /we hereby acknowledge that I/we am aware of the conditions stated in this agreement and agree to abide by these requirements.
Parent/Guardian Signature
Date
Parent/Guardian Signature
Date
Program Director – Cheryl Jameson
Date
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