FLYERS AFTER SCHOOL PROGRAM APPLICATION FOR CHILD. Childs Information. Date of Application: Child s Name (first & last name)

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1 FLYERS AFTER SCHOOL PROGRAM APPLICATION FOR CHILD *All information must be complete in order to enroll Childs Information Child s Name (first & last name) Name of School and Grade Date of Birth Date of Application: Nickname Enrolled in daycare presently? Where? Code Word for Pick Up Gender (M or F) Complex Member (Yes or No) Address Family Information Primary/Guardian (first & last name) Parent Date of Birth Address (street # & name) City, State, Zip Home Phone Work Phone Cell Phone Secondary/Guardian (first & last name) Parent Date of Birth Address (if different from primary) City, State, Zip (if different from primary) Home Phone (if different from primary) Work Phone Cell Phone

2 Emergency Contact Information Please list at least one other person to be contacted in case of an emergency other than the child s parents. First & Last Name Address (street # & name) Relationship to Child City, State, Zip Home Phone Work Phone Cell Phone Pick up list- Please list any other people that are allowed to pick up your child from the FLYERS program. Identification and prior notification the site coordinator will be required. First & Last Name First & Last Name First & Last Name First & Last Name Health & Medical Information List Any Health or Medical Conditions List Current Medications* and Side Effects *If you child is taking medication, you must complete Authorization to Administer Medication Form. Physician s Name Physician s Phone Number List any additional information that staff need to be aware of for the well-being of your child.

3 I verify that my child is of good mental and physical health, and may participate in the Anne Springs Close Greenway FLYERS After School Program. I also verify that my child s immunization shots are up to date. I give permission to authorize emergency care to my child in the event that neither I nor the physician can be contacted. I prefer my child be transported to Hospital, in the case of an emergency. _ Signature of Parent/Guardian Date Insurance Insurance coverage is a requirement to participate in any Leroy Springs & Company, Inc. (parent company of Anne Springs Close Recreation Complex) program. I, the undersigned, Parent or Legal Guardian of the registered participant, certify that the name participant is covered by an insurance program with Company, which will compensate for injuries incurred while participating in FLYERS activities. Signature of Parent/Guardian Date Revised 03/7/2014 KM

4 FLYERS AFTER SCHOOL PROGRAM ENROLLMENT AGREEMENT CHILDS NAME: SCHOOL ATTENDING: UNDERSTANDING I understand that I am enrolling my child in the Anne Springs Close Greenway FLYERS After School Program. I understand that my child s records (contacts, phone numbers, s, and authorized pick-ups) are my responsibility to keep current and accurate. I will update my child s records by filling out an updated form and submitting it to the Site Coordinator or Member Services Desk at the Complex whenever there is a change. REGISTRATION FEE S, WEEKLY PAYMENTS, LATE PAYMENTS & HOURS OF OPERATION I understand that there is an annual registration fee of $75 that is non-refundable due at the time of enrollment. I understand that I am responsible for making payments on a weekly basis and that payments are due seven days prior to the program week. A $20 Late Fee will be enforced for payments not received on time. If the weekly payment is not received the prior week, I understand that my child will not be able to attend the FLYERS program during the week of non-payment. I will receive notice of nonpayment and understand that my child may not attend for the week of non-payment until payment is received or accounting is contacted to set up a payment plan. Children with outstanding balances will not be able to attend FLYERS. Initial that I understand the above paragraph I understand that Hours of Operation are from school dismissal to 6:00 pm. A $10 Late Pick Up for every 15 minutes (6:01-6:15 = $10, 6:16-6:30 = $20) will be required to be paid the next day at the Complex Member Services Desk each time I am late picking up my child. On the third late pick up, I understand the charges are $20 for every 15 minutes that I am late. On the fourth occurrence, I understand that my child may be removed from the program. EARLY WITHDRAWAL I agree to give a two week notice in writing when withdrawing my child from the program by filling out a cancellation form. During the two week notice, I agree to make scheduled FLYERS payments.

5 WHERE TO MAKE PAYMENTS Program payments should be made at Anne Springs Close Greenway Recreation Complex. Convenient Automatic Weekly Credit Card Payments are available and encouraged. Payment by cash, check or credit card is also accepted. Please note that we cannot accept FLEX Childcare Credit Cards or DSS ABC Vouchers for payment. Credit card payments must be called in to the Member Services Desk at by Monday. The Complex is open seven days a week. I understand that full payment is due for every week during the school year; this includes partial weeks and full day weeks. Anne Springs Close Greenway cannot refund due to absences, illness, inclement weather or vacations. *HOLIDAYS, TEACHER WORKDAYS & EARLY SCHOOL CLOSING I understand that there are some holidays & teachers workdays that FLYERS will not be open. FLYERS will be open on most teacher work days. The children are required to bring their lunch to all full days. I will have to sign up two weeks in advance to secure a spot. There is no additional charge for Full days but prior reservations and account update are mandatory, so I will need to plan ahead. Full day sites will be posted in advance. FLYERS will be open for half-days. The children are required to bring their lunch to all half days. There is no additional charge for half days or full days. I understand that FLYERS will be closed during Christmas week with no program payment required. FLYERS will not be in session on the following days: September 1, 2014 January 1, 2015 November 26-28, 2014 April 3, 2015 December 22-26, 2014* May 25, 2015 June 5, 2015 *There is no program fee for this week. FLYERS will be operating on a full day (7 a.m. 6 p.m.) schedule on the following days: October 24, 2014 January 2, 2015 November 4, 2014 January 16, 2015 December 18-19, 2014 January 19, 2014 December 29-31, 2014 February 16, 2015 March 13, 2015 March 30-31, 2015 April 1-2, 2015

6 I understand that if school is closed early or closed for the day due to inclement weather, the FLYERS program will not meet. Anne Springs Close Greenway cannot refund for absences due to illness or inclement weather. Initial that I understand the FLYERS program policy on refunds. SCHOOL FURLOUGH DAYS In the event of Furlough Days through Fort Mill School District where the schools are closed, Anne Springs Close Greenway will do everything possible to offer FLYERS at an alternative site, however there will be no guarantee that FLYERS will be in session during Furlough Days. Anne Springs Close Greenway will notify parents with the alternative sites. There is no additional fee for Full Days. ABSENCES DURING PROGRAM I understand that in the event of any absences during program hours, I will be responsible for fees for time reserved, not for actual time spent at the program. This would include any vacation time. AUTHORIZED PICK UP I understand that my child will not be released to any unauthorized person. I must show a form of identification and sign my child out daily. PERMISSION- The FLYERS program tries to provide as many fun and enriching activities as possible. This will include field trips to various destinations around the Anne Close Springs Greenway and the swimming pool at the Complex on the Greenway in addition to others. The FLYERS program will arrange all transportation to and from each field trip and prior notice will go out to all parents. Please initial each item I hereby give my child permission to participate in all activities of the program including swimming and field trips. I give my child permission to leave the program site for trips in a school activity bus or chartered transportation to off-site locations and enrichment programs. I understand that I will be notified before each activity. I give my child permission to walk to points of interest in close proximity to the program site under FLYERS supervision. I give permission to have my child appear in any ASC Greenway media coverage or brochures. I give my child permission to watch PG movies.

7 MEDICAL AUTHORIZATION I authorize the FLYERS Site Coordinator or designee to administer medication when necessary. I understand that I will have to sign a medication authorization form before any medication can be administered. FLYERS staff will not administer shots (other than an epi pen) or suppositories. STAFFING I understand that FLYERS is not staffed to serve children who need one on one direct care. We do our best to maintain the child to staff ratio of 10 to 1 at all times. All children who attend FLYERS must be able to use the toilet without assistance. FLYERS BEHAVIOR POLICY I understand that my child will have to abide by the FLYERS policies and procedures to ensure that each participant remains safe. My child will be taken away from activities when he/she cannot behave in a safe, expected and kind manner. I will be informed of unacceptable behavior and asked to sign a discipline form. I understand that fighting of any kind will not be tolerated and will result in an automatic suspension. If behavior continues to be a problem, the Site Coordinator will have the discretion to suspend my child from the program. If behavior does not improve, as a last resort, my child will be removed from the program. FLYERS staff do not use corporal punishment. By signing this form, I understand and agree to the policies set forth upon this document. Father/Guardian Signature & Date Mother/Guardian Signature & Date *Dates are subject to change 03/7/2014KM revised

8 FLYERS AUTOMATIC CREDIT CARD PAYMENT PROGRAM Anne Springs Close Greenway is pleased to offer you the pre-authorized payment plan service for your convenience. Your FLYERS fee will be automatically charged to your credit card each week. This plan eliminates the need for you to call each week to charge your credit card and allows us to better service your account. Instructions: Complete the Automatic Credit Card Payment Authorization Form on this page and make a copy of the completed Authorization Form for your records. Forms can be dropped off at the Complex or mailed to: Anne Springs Close Greenway P.O. Box 280 Fort Mill, SC Attention: Erin Ciechowski I authorize Anne Springs Close Greenway to initiate charges to my credit card account. I authorize the credit card company named to accept these charges to my credit card account. These payments will be charged as indicated below. The tuition amount and payment schedule is listed below by class. Note that any changes in membership status will affect your automatic credit card tuition payment. This authorization is to remain in effect for the ASCG FLYERS Program. To cancel this automatic payment, I must provide written notice of cancellation to ASCG not less than 10 days prior to the next scheduled payment. ASCG may terminate this payment plan upon notice of two (2) declined transactions. ASCG reserves the right to cancel this agreement with prior written notice. ASCG will notify me of any changes in the dollar amount charged to my account. ASCG shall not be liable for losses caused by the credit card company s failure to act in accordance to this request. Child s Name (Please Print) FLYERS Site Cardholder s Name Home Address City State & Zip Code Phone Address (s) Effective Dates of this Authorization: August 11, 2014 May 25, 2015 Weekly charges will be processed seven days in advance of the Monday attendance date. Amount (Check One): ( ) $60/Member ( ) $65/Non-Member Type of Credit Card to be Charged (Check One): ( ) Visa ( ) Mastercard ( ) Discover ( ) American Express Credit Card Number Expiration Date (MM/YY) Customer Signature Date FOR OFFICE USE ONLY: Date Authorization Entered: Completed By:

9 FLYERS ASCG PHOTO/IMAGE/SOUND RELEASE CHILD S NAME I hereby grant permission, without reservation, to Anne Springs Close Greenway the unqualified right and permission to take and to use photographs and/or sound image/recordings of me or that of a child of whom I am the legal guardian, and to describe, same for the promotion of announcing, advertising and marketing the activities of Anne Springs Close Greenway. I fully understand that no monetary payment will be made to me for such uses as described above. I release Anne Springs Close Greenway, its officers, directors, agents, employees, volunteers, licensees, assignees, successors and those acting upon their authority, from all claims which I may have, or might have, for any cause of action arising out of the taking and/or use of the photographs and/or sound/image recordings. Parent/Guardian Name (print name) Parent/Guardian Signature Date address

10 FLYERS PROGRAM AUTHORIZATION TO ADMINISTER PRESCRIBED OR NON-PRESCRIBED MEDICATION TO PARTICIPANT WHILE IN THE FLYERS PROGRAM. Name of Child: Date: I hereby request the FLYERS Staff, through its designated authority, to administer the medication herewith provided according to the instructions contained on this form, to my child. Prescription drugs and other medication required by your child must be in the original container and clearly labeled with the child s name and dosage schedule, and must have written directions for administering the medication. Please enclose medication in a labeled zip lock bag. Name of Medication: Dosage: Time Medication is to be given: Possible side effects, if any: Physician s Name: Physician s Address: Physician s Phone: ///////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////// EMERGENCY MEDICAL TREATMENT (Please sign this section in case we need to transport child to a medical facility) I agree that the supervisor may authorize the physician of his/her choice to provide emergency care in the event that neither I nor our family physician can be contacted immediately. Date: Signature of Parent/Guardian