SLAM Nevada Extra Innings Program Enrollment Form

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Before and After School Care 2023-24 School Year
All students must have a completed form on file in case of emergency need for Extra Innings.

Please complete one form for every student K-5.

STUDENT FIRST NAME *

STUDENT LAST NAME *

STUDENT GRADE *

Kinder

Teacher

STUDENT DATE OF BIRTH *

YYYY

BEST CONTACT PHONE NUMBER #1 *

CONTACT PHONE NUMBER #2

PARENT/GUARDIAN #1 NAME *

PARENT/GUARDIAN #2 NAME *

BEST CONTACT EMAIL ADDRESS #1 *

CONTACT EMAIL ADDRESS #2

EMERGENCY CONTACT OTHER THAN PARENT NAME *

EMERGENCY CONTACT OTHER THAN PARENT PHONE NUMBER *

OTHER ADULTS AUTHORIZED TO PICK UP STUDENT *

Will your student regularly need AM Extra Innings? ¿Necesitará su estudiante con regularidad AM Extra Innings? *

Yes, my student will attend Extra Innings in the morning on a regular basis./Sí, mi estudiante asistirá a Extra Innings en la mañana de forma regular.

No, my student will not attend Extra Innings in the mornings./No, mi estudiante no asistirá a Extra Innings por las mañanas.

How will your child go home? Students will only be released to adults who have the correct Silent Dismissal signage. Individuals who do not have signage will need to go into the office to check students out through Infinite Campus. This requires an ID. ¿Cómo se irá su hijo a casa? Los estudiantes solo serán entregados a adultos que tengan la señalización correcta de Salida silenciosa. Las personas que no tengan señalización deberán ir a la oficina para registrar la salida de los estudiantes a través de Infinite Campus. Esto requiere una identificación. *

My student will be picked up in the carline./Mi estudiante será recogido en la línea del automóvil.

My student will be picked up at the school entryway./Mi estudiante sera recogido en la entrada de la escuela.

My student will walk/bike home independently./Mi estudiante caminará / irá en bicicleta a casa de forma independiente.

My student will attend Extra Innings./Mi estudiante asistirá a Extra Innings.

Other:

KNOWN ALLERGIES *

MEDICAL CONCERNS *

SELECT EACH COMMENT TO ACCEPT TERMS *

I understand that if my child is not registered for Extra Innings and is not picked up after school, Henderson Police Department will be notified.

I will be responsible for all fees, which may be incurred.

FEES: I understand that if my child attends weekly, the payment is due by the Wednesday before the week my child attends.

I understand that if my child attends daily (drop-in) the payment is due immediately.

I understand a delinquent account will result in my child being dismissed from the program until the account is current.

LATE PAYMENT FEES: I understand that weekly payments made after the due date will result in an additional $5.00 and Late Daily Drop-In payments will result in an additional $1.00 per day payment is not made.

LATE PICK-UP FEE: I understand in the event my student is not picked up by 5:30 pm, a late fee of $1 per minute, per child, will be added to the total rate.

LATE PICK-UP PROCEDURE: At 6:00 pm, if no one has arrived for the students, authorities will be called to transport the student to another facility for pick up. If a student is not picked up by 6:00 pm twice during the school year, the student will be dismissed from Extra Innings for the remainder of the semester.

NON-SUFFICIENT FUNDS FEE: I understand that a $25.00 NSF fee will be assessed for each returned check. All future payments must be made by cash or money order only.

I will not be credited for any missed days for enrollment by the week. Any advance payments for Drop-ins will be applied as used.

I understand my student will be signed into Extra Innings when he/she is not picked up by the end of the school day. Only the adults listed on the Participant Information form are authorized to pick up the student named on the enrollment form.

I will make other arrangements for emergency closings, delays and dismissals. I understand that Extra Innings is not in session when the school is closed (holidays and breaks).

I understand that my child may bring appropriate personal belongings to the program and I will not hold SLAM Nevada or Extra Innings responsible for replacement or repair of any items that may be lost, stolen, or broken.

I understand that if my child is posing a serious or recurrent discipline problem, he or she may be suspended or dismissed from the program and the balance of my account must be immediately paid in full.

I understand participating students are expected to attend both portions of the program each day.

Any violation of SLAM Nevada school rules while attending the after-school program including fighting, possession of forbidden items, destruction of school property, or other rules may result in removal from the after-school program.

For and on behalf of the minor child named as participant herein, myself, my spouse, if any, and our heirs, executors and administrators, I hereby due expressly and forever waive and releaseSLAM Nevada Extra Innings and all their respective officers, employees, agents or representatives from any and all liability for personal injury or damages sustained, incurred, arising from, or connected with the program or activity described.

Required

PARENT ACKNOWLEDGEMENT: BY TYPING MY NAME BELOW I ACKNOWLEDGE THIS AGREEMENT WITH EXTRA INNINGS, SLAM NEVADA *

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