Galaxy Kids School-Age Childcare Summer Contract/Registration Form
2017 Summer Program. Please fill out a separate form for each child.
Child's First name
Child's Last Name
Child's Date of Birth
Child's Grade for 2017-18 School Year
Child's T-Shirt Size
Children's sizes. Once t-shirts are ordered, alternate sizes will not be available.
Names of Parents/Guardians
Email Address of Parent/Guardian
Most emails will be sent to the email addresses listed on your Parent Portal.
Name and phone number of person responsible for payment
Full Day Care 6:00am-6:00pm
Partial Day Care 5.5 hours or less. Not available on field trip days.
Please note you must schedule a minimum of 8 days per month if selecting the calendar option. If you select less than 8 days per month you will be billed the drop-in rate.
Calendar Option (Calendars due monthly. If you select Calendar Option, you MUST turn in a Calendar or you will be charged a late fee.)
Drop-In Option ( Care as needed-not pre-scheduled or if you need less than 8 days per month. Drop-in care is an additional $2.00 per day.)
Who should we call if your child is ill or if there is an emergency?
Please list name and phone number.
Please list the names of all people authorized to pick up your child.
Please list any allergies or medical information Galaxy staff should be aware of.
This information will only be viewed by GKP staff. If no allergies or medical information, please enter "None". If your child requires medication during program hours, please contact Galaxy staff for a Medication Authorization Form.
Please list special health or developmental needs Galaxy staff should be aware of.
This information will only be viewed by GKP staff. If no health or developmental needs, please enter "None".
By checking the box below you are stating you have read and agree to abide by the Galaxy Kids Program Handbook/Policies.
The Galaxy Kids Program handbook is available on our website or on-site in our classroom.
I have read and agree to the GKP handbook and policies.
Galaxy Kids Program Contract Information
Please read each of the statements below carefully and check the box next to each one to acknowledge you understand each statement. If you have questions, please contact Galaxy staff before completing this form. All registrations are due by May 15. Registrations received after May 15 will be placed on a waiting list and you will be contacted with a start date when space is available.
I understand that I will be charged a non-refundable registration fee at the time my registration is processed. $35 per child/$65 per family for registrations received by May 1. $40 per child/$75 per family for registrations received after May 15.
I understand if I have selected the calendar option my calendar is due on the 1st of the month prior to care and that there is a $25.00 late fee for calendars turned in after the 1st of the month.
I understand that payment will be billed monthly in advance. Invoices will be available on the 15th of the month prior to care.
I understand payment is due for invoices by the 25th of the prior month (example: Sept. payment is due Aug 25).
I understand if my payment is not received by the 25th of the month, a $25 late fee will be charged.
I understand I am required to pay for each day indicated on my calendar form for each month.
I understand if my child will not be attending GKP on a scheduled day, I am required to notify GKP staff by 9:00am. If I do not notify GKP by 9:00am, a $5 Finders Fee may be applied to my Parent Portal.
I understand I must enter the building and sign my child in and out on the attendance sheet each day and make contact with GKP staff before leaving.
I hereby grant permission for my child to leave the school premises under the proper supervision for: walks, in-town outings, public library or field trips in a authorized school vehicle
I have my current emergency contact information updated in my Infinite Campus parent portal. If I do not have a campus portal I will contact the GKP office to obtain one.
I understand that in the event of a serious accident, injury or illness, I authorize GKP to call 911 before notifying me or my physician. If an ambulance is necessary, GKP will not be held responsible for any cost this action may incur.
I am the legal parent/guardian of the student named on this form.
My child attends Rockford Area Schools.
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