Ada Schools - After School Program
***** PROGRAM AVAILABLE FOR PRE-K to 2ND GRADE ONLY *****
Parent/Guardian must complete and submit entire form, including Affirmation Statement and digital signature for enrollment to be valid.
2016-2017 Ada Schools After-School Program Fees
Enrollment Fee: $20.00

Monthly Rate: $100.00
Weekly Rate: $30.00
Daily Rate: $7.00

STUDENT INFORMATION:
Student Full Name:
(Please Include Legal First, Middle, & Last Name)
Your answer
School Student Attends:
Current Grade:
Classroom Teacher:
Your answer
PARENT/GUARDIAN INFORMATION:
Mother / Guardian Name:
Your answer
Cell Phone or Contact Phone:
Your answer
Email:
Your answer
Mother - Place of Employment:
Your answer
Father / Guardian Name:
Your answer
Cell phone or Contact Phone:
Your answer
Email:
Your answer
Father - Place of Employment:
Your answer
EMERGENCY CONTACTS & RED ALERTS:
Emergency Contact:
Your answer
Emergency Contact Phone:
Your answer
Others authorized to pick up student:
Your answer
People Prohibited from picking up Student:
Your answer
Siblings attending Ada City Schools:
Your answer
Parent/Guardian Payment Method
(Please select method and frequency of payment below.)

Enrollment Fee: $20.00

Monthly Rate: $100.00
Weekly Rate: $30.00
Daily Rate: $7.00

Method Of Payment:
E-Funds
Check
Cash
Payment Type:
Payment Schedule:
Weekly (Every Friday)
Bi-Weekly (Twice a Month)
Monthly (Once a Month)
Frequency Of Payment:
ENROLLMENT SIGNATURE AND VERIFICATION
Parent must check the Enrollment Affirmation Statement, and type full legal name below to complete enrollment process.
Parent/Guardian Enrollment Affirmation Statement
Required
Parent/Guardian Signature
(Type Parent/Guardian Full Legal Name in the space below)
Your answer
Submit
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