Nanuet Family Resource Center School Age Care

Application/Registration 2024-2025 School Year

(Please print clearly; applications that can’t be read will not be processed)

Child’s First Name: _________________ Child’s Last Name: ___________________

Home Address: __________________________________________                        

Home Phone __________________ Family e-mail ____________________________

Date of Birth: ___/___/____    Age as of Sept. 2024:_______    Gender:  Male  Female Non-binary

Original Program Start Date: ___/____      2024 Start Date: ___/___/____

Grade 9/24:_____ Teacher: __________

FRC Program Site:    Miller    Highview    Barr  

All programs run 5 days a week when school is in session.

Each program will run with a minimum of 10 children

Parent/ Guardian Information:

Parent 1: Name: _____________________________   Cell Phone: _________________

Place of employment:                                           Work Phone: _______________   

E-mail: _______________________________________

Address: if different from child’s (include city, state & zip) __________________________________

Parent 2: Name: _____________________________   Cell Phone: _________________

Place of employment:                                           Work Phone: _______________   

E-mail: _______________________________________

Address: if different from child’s (include city, state & zip) __________________________________

Emergency Treatment Release:

I, ___________________________give permission for my child ____________________

to receive emergency medical treatment or other treatment deemed necessary.

Emergency Transportation Release:

I, ____________________________give permission for my child ___________________

to be transported by the Nanuet FRC program to a safe location in case of an emergency.

(We do not transport children unless there is an emergency)

Waiver: 

If I am unreachable, I hereby give permission to the staff to obtain proper medical care in case of injury or illness. I agree not to hold FRC, staff or related parties liable and not to make any claims against them. The student’s personal insurance company is the primary company on any medical claims and I remain liable for anything not covered by insurance.

Medical Information: please be as specific as possible when answering the following questions. Doctor & Dentist information MUST be complete for entry in to the program.

Doctor: Name: ____________________________ Phone: ___________________

Dentist: Name: ____________________________Phone: ___________________

Allergies: ____________________________________________Must fill out additional forms prior to start.

Medications: __________________________________________Must fill out additional forms prior to start.

Does your child have an IEP? (Individual Education Plan) Yes/ No

Page 1 of 4                                                                                                     Parent initials______ & Date______

          Nanuet Family Resource Center

School Age Care

2024-2025

Please list other household members:

Name: _________________________ Age: ________ Relationship: _______________

Name: _________________________Age: ________ Relationship: ________________

Name: _________________________Age: ________ Relationship: _________________

Emergency Contacts: At least two contacts other than parents/guardians already listed, must be provided. We will always try to contact you first.

Name                                        _                Cell Phone                                         

Secondary Phone                                          Relationship to child                                 

The above person is authorized to pick up my child:  Yes ____ No ____

Name                                                        Cell Phone                                         

Secondary Phone                                         Relationship to child                                 

The above person is authorized to pick up my child:  Yes ____ No ____

Authorized Pick-ups: Adults, other than the parent/guardian and emergency, contacts that have your permission to pick up your child.  Their ID is required at pick up.

You must provide at least one adult.

Name: ___________________Phone: ______________ Relations to child: ________

Name: ___________________Phone: _______________Relations to child: ________

Name: ___________________Phone: _______________ Relations to child: _______

Attach an additional page if adding additional Authorized Pick-ups. You may add people to this list at any time. Please send an e-mail or written notice to your Site Supervisor.

• Every family that registers a student for SAC/MAP must be on the district’s K-12 Alert. This is how parents are notified when SAC/MAP is cancelled due to bad weather or other circumstances. Students will be instructed to go home on their regular dismissal bus unless you provide an alternate plan.  When changes in this plan occur, please contact your child’s school directly to ensure your child is dismissed to the proper place.  If you are unsure if you are on the K-12 Alert or need to update your information, please contact:

District’s Registrar: 845-627-9883

Please indicate your choice below:

______ If SAC/MAP is cancelled my child is to take the bus home.

______ If SAC/MAP is cancelled my child will be a walker and be picked up.

If special instructions are required please contact your child’s teacher or the front office of their school.  Staff does not arrive until 3:15 at Miller and Highview and 2:30 at Barr.

Page 2 of 4                                                                     Parent initials______ & Date______

          Nanuet Family Resource Center

School Age Care

2024-2025

Fee Statement:

The billing for this program is divided into 10 equal payments throughout the school year and remains the same each month regardless of school holidays, absences or snow days. These fees take into account the exact number of days the program will be in session according to the school’s calendar. We do not pro-rate, refund or exchange for days missed for any reason.

Fees due at registration:

• With this registration packet there is a $50 per family annual registration fee; this fee in non-refundable.
• You will be billed the registration fee on Brightwheel
• Registration forms MUST be completely filled out and returned to the Nanuet FRC. Please give a minimum of five business days prior to your child’s anticipated start date.   Please note that the start of the school year may require a longer registration time. All information must be emailed to spollack2@nanuetsd.org.
• Payments can be made via brightwheel through either a bank account (0 fee) or a credit card (2.95% fee)

Monthly Fees: (please circle to select your child’s rate plan)

• This contract is for the entire school year.
• There is a $100 cancellation of contract fee and a 30-day notice to withdraw from the program.

Payment Information:

All families MUST be set up for electronic payments. You can use a Credit Card, Checking, or Savings Account. All payments will be processed on the first of each month.  

All account information is to be entered by the adult responsible for payment.  This information will be entered by you directly onto the Brighwheel app once you have received an invitation.

I _____________________________________ authorize the use of my credit card/checking/ savings account for monthly payments of my childcare according to this contract.

Signature ___________________________ Date    ________________                                          

If a payment is declined or returned for insufficient funds, a $35 processing fee will be added to your account.

• Families whose tuition payments fall more than one month behind can be withdrawn from the program.
• If I withdraw my child’s enrollment during the month, no tuition will be refunded for that month. A 30 day request in writing is required before your withdrawal.
• If I choose to cancel the contract before the end of the school year, I understand that there is a $100 fee for cancellation of services.
• If the school district is required to close due to a communicable disease and the program will no longer be able to service families, no cancellation of contract fee will be charged.  If the program is in session for at least 1 day the monthly the payment will be required with no refunds.
• Receipts from Brigthwheel are available and best accessed by a laptop.  It is your responsibility to keep these receipts for tax purposes.  

Page 3 of 4                                                                        Parent initials                 & Date                

Nanuet Family Resource Center

School Age Care

2024-2025

Policy Information: A parent handbook will be sent to you via e-mail or on Brigthwheel once your registration is received. Please review our policy information and return the parent signature page prior to your child’s start date. Your child will not be able to start the program if the parent signature page is not signed and turned into the director.

• The $50.00 registration fee is non-refundable.
• There are no credits, exchanges or pro-rations made for missed days for any reason.
• I hereby give permission for my child to be photographed and for the photos to be used in educational and/or promotional materials that include but are not limited to the internet, produced by the Nanuet Family Resource Center. I hereby give permission for my child to be posted on Brightwheel which will be a form of communication between the program and the families we service. Further, I understand that there will be no compensation for the use of these photos.
• I understand that there is a $100 cancellation fee for terminating this contract prior to the end of the school year and that such cancelation MUST be in writing a minimum of 30 days prior to cancel date requested.
• I understand that there is a $50 re-enrollment fee should I cancel the contract and then re-enroll my child during the same school year.
• I understand that there is a $25 late fee for every 15 minutes or portion thereof that I am late for pick up. I further understand that these fees will be billed on Brightwheel. In addition, I understand that if I am late on a regular basis my child may be removed from the program at the discretion of the Nanuet FRC Director and that I will not be entitled to any refund of fees paid.
• I will abide by the program’s protocol that requires me to sign my child in at the before school program and sign them out at the after school program on the Brightwheel app.
• If I am unreachable, I hereby give permission to the staff to obtain proper medical care in case of injury or illness. The student’s personal insurance company is the primary company on any medical claims and I remain liable for anything not covered by insurance
• Once a completed registration package is submitted, it will be processed (can be up to 1 week), you will receive an email verifying that your child is enrolled.
• Families must log onto brightwheel, enter billing information, and turn on auto pay as that is part of our contract.  Auto pay is required to be on for the entire school year.

I have read, understand and agree to the above terms and conditions

Print name: _________________ Signature: __________________ Date: __________

Print name: _________________         Signature: __________________ Date: __________

Please return completed application with payment to:

Nanuet FRC    50 Blauvelt Road    Nanuet, NY 10954

(Forms can be mailed, e-mailed, faxed 845.624-1534 or dropped off)

Shannon Pollack, Nanuet Family Resource Center School Age Care Director

845-627-4891-office, 845-558-9630-cell  spollack2@nanuetsd.org

RoseAnn Mercado, Nanuet Family Resource Center Executive Director

845.627-4889-office, 845-596-2720-cell   rmercado@nanuetsd.org

Page 4 of 4                                                                        Parent initials                 & Date                        

———————————————For Office Use Only —————————————–————

Completed application received on date: ____/____/____ By: ________________

Entry date: ___/____/____ By: ___________________

          Nanuet Family Resource Center

School Age Care

2024-2025

Parent Handbook Receipt

This letter acknowledges that I _____________________ have received, read and agree to all of the terms, conditions, policies and information provided in the Parent Handbook for the 2024-2025 school year.

• I understand the morning program begins at 7:00am at Miller and Highview and my child(ren) can be dropped off anytime from 7am to 8:40am.  Please note that staff may be present before 7:00am, drop off officially does not occur until 7:00am.
• I understand that the program ends at 6:00 at Miller and Highview and 5:30 at Barr. My child(ren) must be picked up by that time.

• I understand all of the fees associated with late pick up, change in attendance schedule, early termination of the contract and re-entry.
• I understand that tuition reminders, updates, newsletters and important program information will be received through Brightwheel.
• I give consent for my child to participate in all program activities.
• I understand that failure to make payments in a timely manner may result in an automatic withdrawal from the program, and no refunds will be given.
• I understand my family MUST be registered with the Nanuet School District’s K-12 Alert because this will be the method used to notify me of SAC/MAP cancelations due to weather or other circumstances.
• I will keep my contact information up to date with the Site Supervisor, Program Director and the K-12 Alert program.
• Waiver: If I am unreachable, I hereby give permission to the staff to obtain proper medical care in case of injury or illness. The student’s personal insurance company is the primary company on any medical claims and I remain liable for anything not covered by insurance.
• Further, I agree not to hold the Nanuet Family Resource Center, staff, the Nanuet Union Free School District and its employees/officers or related parties liable or to make any claims against them for any injuries suffered during this program or for medical treatment authorized by them.

Child(ren)s Name: _________________________________________________

                              _________________________________________________

Parent/ Guardian (print): ________________________________

Parent/Guardian (signature): _____________________________

Date: ___________________

Please return this form to the Nanuet Family Resource Center before your child(ren)’s first day:

Nanuet Family Resource Center

50 Blauvelt Rd.

Nanuet, NY 10954