2018-19 Extended Day Program: Online Application Form

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YOUR CHILD MAY NOT PARTICIPATE IN THE PROGRAM WITHOUT THIS FORM
Please scroll down the form, execute all parts and press “SUBMIT”

Child's first name *

If you are applying for more than one child, please use a SEPARATE APPLICATION FORM FOR EACH CHILD

Child's last name *

If you are applying for more than one child, please use a SEPARATE APPLICATION FORM FOR EACH CHILD

Part I. Operating Policies and Conditions

The Stoddert Extended Day Program (EDP) is a tax-exempt business (EIN #52-1195083). Observance of financial obligations and the conditions stated below govern participation in the program. The Director advises the Extended Day Program Board on any breach of these terms and makes recommendations on any child's or parents' continued participation. The Board acts as a review panel in all disputed situations. Its decisions are final and may not be appealed.

Payments" *

Please CHECK ALL BOXES to indicate your understanding and consent

1. The EDP maintains a financial, administrative and collaborative decision-making relationship with the Stoddert PTO. All participating families must pay their PTO dues. This fee can be paid in full ($400 lump sum) or monthly ($40 per month, in addition to Extended Day Fees).

2. There is a one-time EDP $30.00 registration fee.

3. Payment is due no later than the fifth day of the month during which childcare services are provided. Payments run from September 5th through June 5th.

4. A $25.00 late fee is assessed against all account balances after the 5th of the month. A $25.00 bounced check fee is applied to any check returned for insufficient funds.

5. Requests for withdrawal from the EDP or a change in enrollment status must be made by submitting a “Request for Change in Enrollment Status” form no later than the 25th day of the month prior to the month when the change in enrollment status is requested to be effective.

6. There will be no refunds or pro-rata reduction in fees for the month when a change in enrollment status is effective if the “Request for Change in Enrollment Status” form is submitted after the 25th day of the previous month.

7. Participation in the EDP may be suspended if monthly fees are not paid in a timely manner. If you are having difficulties paying your fees, please contact the Director as soon as possible.

8. Change in enrollment from part to full-time after care is made at the discretion of the Director subject to availability of space. Requests for change in enrollment status must be made using the online “Request for Change in Enrollment Status” form

Required

Schedule and Operations *

Please CHECK ALL BOXES to indicate your understanding and consent

9. The before care program operates from 7:30-8:45 am. Children MAY NOT be dropped off before 7:30 am. A parent or guardian must accompany their child to the cafeteria and sign them in with a before care staff member.

10. The after care program operates from 3:15-6:00 pm on regular school days, and from 12:15-6:00 pm on DCPS half days (there is an additional fee for half day childcare). Children must be picked up by 6:00 pm. There is a $1.00 per minute late fee charged for any child picked up after 6:00 pm. The late fee must be paid, in cash, at the time of pick up.

11. You must inform the Director if your child has any special dietary or medical needs.

12. Children may not attend if they are ill. The Director has the discretion to determine whether a child is too ill to participate in the program. EDP staff may not administer any medications to children attending the program.

13. Each child MUST be picked up and signed out of the program each day by an authorized person. Only persons named on your child’s registration form can pick up and sign out your child without additional notice. If alternative arrangements for pick up have been or need to be made, the Director or a member of the staff must be informed in person, in writing or email, or by phone with the name of the person who is authorized to pick up your child prior to pick up.

14. Names and telephone numbers of those authorized to pick up children must be on file and current. Send written notification of any changes.

15. Children attending the program may not leave the Stoddert school grounds for classes, team practices, or for other reasons without an email or a permission note with your signature.

16. Children participating in the program will play outdoors on the playground each day (weather permitting). It is essential that your child come prepared with appropriate clothing to be able to play outdoors.

17. There is no before or after care on any days that DCPS is closed. There is no before care if DCPS calls for a late opening. There is no after care if DCPS orders early school closing for any reason during the day (e.g. snowstorms).

18. The program’s goal is to create an environment where the children and staff feel safe, protected and respected. The following rules will be followed: follow all school rules; follow directions given by staff; respect the rights, privacy, personal space and possessions of others; stay in assigned areas under the supervision of EDP staff or any other adult working with the program; show respect for all property and equipment; use appropriate language; use the restrooms appropriately; no sharing or throwing food, clean up space after eating snack and throw away trash; do not throw rocks or other harmful objects; no fighting or bullying. Repeated violation of the rules may result in a child being suspended or no longer allowed to participate in the program.Behavior that endangers the health and/or safety of any child or adult may result in immediate suspension and/or termination from participation in the Program.

19. You must inform the Director if your child will not be attending before and/or after care on any given day.

Required

Parents' Consent and Release Clause *

Please CHECK ALL BOXES to indicate your understanding and consent

20. My child may take part in field trips as part of the Stoddert Extended Day Program.

21. On behalf of my child enrolled with this form, I hereby release Stoddert School, DC Public Schools, the Stoddert PTO and the Stoddert Extended Day Program, supervisor and teaching personnel, and all other participants in the program from any and all responsibility and liability for accidents, injuries, or other mishaps and misfortunes involving or related to the program.

22. In case of emergency, I give you permission to provide first aid care for my child and my child may be transported to the nearest medical facility for any treatment deemed necessary (including anesthesia). I agree to accept financial responsibility for all medical expenses incurred.

Required

My/our virtual signature(s) show(s) that I/we have read and agree to all terms of participation in this program *

Parent(s) first and last name(s) here

Part II: Services and Payment Information

Payments for EDP services can be made only by credit card. Credit cards will be charged on the 5th of each month for the amount stated in invoice.

PTO Dues Payment Options (payable per family) *

Paying PTO dues is mandatory. You have the following options to pay your PTO dues: (a) through the EDP as a lump sum ($400.00), or (b) through the EDP as a $40.00 monthly payment throughout the school year, or (c) you can pay the entire $400.00 amount directly to the PTO. Please indicate how you intend to pay.

$400.00 lump sum through the Extended Day Program

$40.00 with my monthly Extended Day Program bill

We/I have already paid the whole amount ($400.00) directly to the PTO

Registration Fee (per each child in the program) *

Please check to indicate you intend to pay the fee

$30.00 (one time fee)

Enrollment (per child) *

Check all that apply

Full-time before care $75.00 per month

Full-time after care $190.00 per month

Part-time after care (2 days a week) $95.00 per month

Required

Enrollment - part-time after care

If you are signing up for part-time after care above, please indicate the 2 days per week your child will attend

Monday

Tuesday

Wednesday

Thursday

Friday

Credit card holder's name as it appears on the card *

We don't accept American Express cards

Credit card number *

We don't accept American Express cards

Credit card expiration month *

Credit card expiration year *

Part III: Emergency Contact Form

Child's grade level *

Guardian #1 name *

First, last

Guardian #1 address *

Guardian #1 cell phone number *

(XXX) XXX-XXXX

Guardian #1 home phone number

(XXX) XXX-XXXX

Guardian #1 work phone number

(XXX) XXX-XXXX

Guardian #1 email address *

Guardian #2 name *

First, last

Guardian #2 address

If different from that of Guardian #1

Guardian #2 cell phone number *

(XXX) XXX-XXXX

Guardian #2 home phone number

(XXX) XXX-XXXX

Guardian #2 work phone number

(XXX) XXX-XXXX

Guardian #2 email address *

Health insurance company *

e. g. Aetna (please spell the name correctly)

Name of health insurance policy holder *

First, last

Health insurance policy number *

Child's pediatrician *

First, last

Pediatrician's phone number *

(XXX) XXX-XXXX

List of all allergies or health problems we should be aware of *

Please specify allergens and describe you child's symptoms

Primary emergency contact *

First, last

Telephone number of primary emergency contact *

(XXX) XXX_XXXX

Back-up emergency contact *

First, last

Telephone number of back-up emergency contact *

(XXX) XXX-XXXX

Name of person #1, other than parents, who is authorized to pick up your child *

First, last

Telephone number of person #1, other than parents, who is authorized to pick up your child *

(XXX) XXX-XXXX

Name of person #2, other than parents, who is authorized to pick up your child *

First, last

Telephone number of person #2, other than parents, who is authorized to pick up your child *

(XXX) XXX-XXXX

Additional names and telephone numbers of persons, other than parents, who are authorized to pick up your child

Submit

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