SPACE Registation 2019-2020
Please complete all required fields below. Your application will be complete when this form is submitted and the SPACE has received your application fee of $40/new student or $30/returning student. Registrations are processed on a first-come, first-served basis.

Tuition rates per week for 2019-20:
1 day: $25, 2 day: $50, 3-day: $75, 4 or 5-day: $100
10% discount applies to second child in a family
Child's First Name *
Child's Middle Name
Child's Last Name *
Child's Nickname
Sex *
Date of Birth *
MM
/
DD
/
YYYY
Age (as of 9/1/2019) *
Grade for 2019-20 school year *
School attending in fall 2019 *
Home Street Address *
City *
Zip Code *
Home Phone
Additional Important Information (allergies, medical info, academic challenges, diagnoses, etc)
Mother/Guardian's First Name *
Mother/Guardian's Last Name *
Mother/Guardian's Employer
Mother/Guardian's Cell Phone *
Mother/Guardian's Work Phone
All of Mother/Guardian's email addresses to which you want communication to be sent *
Mother/Guardian's Home Address (if different than student)
Father/Guardian's First Name *
Father/Guardian's Last Name *
Father/Guardian's Employer
Father/Guardian's Cell Phone *
Father/Guardian's Work Phone
All of Father/Guardian's email addresses to which you want communication to be sent *
Father/Guardian's Home Address (if different than student)
Primary language spoken at home *
Parents are *
Child lives with *
Required
List names and ages of other children in the same household
Emergency Contact 1 Name (2 are required by VA state law) *
Relationship to Student *
Address *
Primary Phone Number *
Contact 1 is authorized to pick up child *
Emergency Contact 2 Name (2 are required by VA state law) *
Relationship to Student *
Address *
Primary Phone Number *
Contact 2 is authorized to pick up child *
List additional persons authorized to pick up child
My child is a *
My child will attend (reduced rates are available on a sliding scale basis with proof of income less than $70,000) *
If part time, choose which days
By signing below, the parent/guardian states that the information on this form is true and current to the best of their knowledge. I understand that my registration payment is refundable only if no space is available for my child. I understand that for new students, a payment in the amount of one week's tuition is due with registration in order to secure my child's spot. For returning students, one week's tuition is due by August 16, 2019. I also understand that subsequent weekly tuition payments are due each Friday for the upcoming week. In the event that I withdraw my child from the SPACE for any reason after submitting my registration, I understand that I will not be entitled to a refund of the sums previously paid unless there is no spot available for my child. I understand that after my child begins, the SPACE must be given two weeks written notice of withdrawal from the program. Students withdrawing from the SPACE after May 15, 2020 must pay tuition through the remainder of the school year. In the event that the SPACE determines, per guidelines found in the student handbook, that it is no longer in the best interest for my child attend the SPACE, the afterschool program may refund sums previously paid for unused days at its discretion. I hereby agree to enroll my child in the afterschool program at the SPACE, and I agree to abide by the financial policies set forth in the handbook and the terms of this registration. *
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