Credit Card Authorization Form ROCK Summer Enrichment Camp 2017
REGISTRATION FOR ALL CAMPS MUST BE COMPLETED 7 DAYS IN ADVANCE. MINIMUM ENROLLMENT IS 4 STUDENTS.
PARENTS WILL BE NOTIFIED OF CONFIRMATION VIA E-MAIL THE TUESDAY BEFORE THE CAMP BEGINS.
CAMPS WITH LESS THAN 4 STUDENTS MAY BE CANCELLED. PARENTS WILL BE NOTIFIED AS SOON AS POSSIBLE.
Student's Name: / Birthdate:
Address: / City: / Zip:
Female Male / Home Phone:
Grade completed 2016-2017
PARENT/GUARDIAN INFORMATION
Primary Account Holder: / Secondary Account Holder:
Authorized to pick up? Yes No / Authorized to pick up? Yes No
Home Phone: / Home Phone:
Work Phone: / Work Phone:
Cell Phone: / Cell Phone:
E-mail: / E-mail:
Child lives with: father mother both parents other: (step/relative/etc.)
*If a parent is not authorized to pick up the child, the ROCK Site Coordinator must receive court documentation to support that decision.
AUTHORIZATION FOR EMERGENCY MEDICAL ATTENTION (listed below are the closest hospitals; please notify us if these aren’t your preference)
Name of Hospital: Choose an item. / Complete Address:
Phone #:
Name of Emergency Contact (not listed above): / Complete Address:
Phone #:
My child’s immunization record is on file at their home campus OR I have provided a current immunization record (ALL new and/or non-RISD students)
List any health conditions or behavior concerns that may require us to take action:
I give consent for this facility to secure any/ all necessary emergency medical care for my child.
Parent/Guardian Signature: Date Signed:
By clicking the box beside “I agree”, you agree that this e-signature is valid as your legal signature. I agree
CAMP SIGN UP
For the camps you would like to register for, place the Camp ID # and Camp Title below. Camp ID #s and Camp Title information can be found on the Camp Schedule & Information file on the ROCK Web site. http://www.rockwallisd.com/Domain/65
Camp ID # / Camp Title
1. / 1.
2. / 2.
3. / 3.
4. / 4.
FEES: $100 per camp (no discounts offered) / ACCOUNT WILL BE BILLED BY NOON 7 DAYS IN ADVANCE
# of camps registered X $100/camp = $ total
charged to card
Please e-mail Credit Card authorization form (below) with registration form to or fax to 469-698-7159. Your account will be charged by noon 7 days in advance. You will be notified of confirmation of enrollment by e-mail. Your child will not be able to attend if payment hasn't been received. Payments cannot be made on campus. Tuition is non-refundable except in cases of camp cancellation.
F O R O F F I C E U S E O N L Y
DATE REC'D: / Start Date: / Account Number:
CC Authorization Form Received:
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GENERAL INFORMATION AND GUIDELINES
RISD is committed to providing equal educational opportunity in all programs and services and maintains a strict policy prohibiting unlawful discrimination. No qualified student shall, on the basis of disability, race, religion, color, sex, or national origin, be excluded from participation in, be denied the benefits of, or otherwise be subject to discrimination under ROCK After School Program. The ROCK program offers group child care arrangements. RISD anticipates that all program sites will offer services and activities in a setting with an adult-to-student ratio of between 1:25. A condition of enrollment in ROCK is that students maintain appropriate conduct and behavior at all times. Students who enroll in ROCK should be able to toilet independently. Our goal is to keep all of the children and staff safe. When students demonstrate inappropriate behavior while attending ROCK, the staff will use many methods of redirection and re-teaching to encourage appropriate behavior. Students who demonstrate persistent behavior problems that disrupt the program and/or interfere with the general welfare and participation of others will be subject to appropriate disciplinary consequences, which may include temporary or permanent removal from the program. Persistent inappropriate behaviors that may result in disciplinary consequences include, but are not limited to, repeated temper tantrums, rudeness, disrespect, noncompliance, property destruction, and physical aggression with students or adults. ROCK will notify parents at pickup times if behavioral problems have occurred. If a child's behavior creates an unsafe situation for the child or others, the parent or another person designated by the parent may be called to immediately pick up the child. In addition, students may be withdrawn from ROCK for nonpayment of fees, continual late payment of fees, or persistent late pick up. ROCK staff strives to maintain a safe and healthy environment for all students but accidents or injuries may sometimes occur despite our best efforts. RISD and ROCK are not liable for any illness, injuries, losses, or other damages a student may sustain while attending ROCK.
PLEASE READ AND INITIAL EACH OF THE FOLLOWING:
*I understand that acceptable behavior is a condition of my child's enrollment in ROCK. My child must follow the rules, policies, procedures set out in the RISD Code of Conduct and that he/she will be subject to consequences under the Code for Misbehavior. Initial
*I understand that all payments are due seven days in advance of each week. There will be no refunds or credits issued for unused days. If enrolled, your child's slot is reserved and the program is staffed accordingly - parents/guardians are still required to pay. If a student is absent for any reason, tuition is still required to be paid. The individual who completes this paperwork is financially responsible for all fees and tuition. I understand that the financial responsibility exists regardless of my student's attendance. Initial
* I understand that cancellations/rescheduling must be done seven days in advance. If done by the due date, your credit card will not be charged. There are no refunds posted to accounts if notified after the due date (7 days in advance). Initial
*By initialing, you authorize RISD and ROCK to use your child's name and photograph(s)/video in RISD district publications which could include but are not limited to: web sites, campus listings, and newsletters.Initial
* I understand the RISD acceptable use of the electronic internet communications system policies as described in the Parent Handbook and give permission for my child to participate. Initial
*All children must be picked up NO LATER THAN 12:00 PM each day unless attending the regular ROCK summer program at Amanda Rochell Elementary. If attending a camp at Grace Hartman, there will be no transportation provided to transfer students to the regular ROCK summer program. Initial
* I have disclosed all known health problems or conditions of my child.Initial
*Transportation is not provided. Initial
*I understand that no meals will be served to my child while in care and I need to send a snack each day. Initial
PERMISSION TO RELEASE
Please list all persons who are authorized to pick up your child besides the parent/guardian. Your child will only be allowed to leave with the persons named. In the event of an emergency, the following persons may also be contacted.
YOU MUST LIST AT LEAST 2 OTHER PEOPLE TO CONTACT AND THEIR PHONE NUMBERS
Name / Relation to Child / Phone #
To add or drop persons from the list, written notice must be given to program staff in advance.
If listed above, my child has permission be released to the care of sibling(s) under 18 years old. Initial
I HAVE READ THIS REGISTRATION FORM. I AGREE TO ABIDE BY ALL THE OPERATIONAL POLICIES AS WELL AS THOSE OUTLINED IN THE PARENT HANDBOOK AND WILL NOTIFY STAFF MEMBERS IN WRITING OF ANY CHANGES MADE TO THE INFORMATION ON THIS FORM. I RECOGNIZE IT IS MY RESPONSIBILITY TO MAINTAIN CURRENT INFORMATION WITH THE PROGRAM AT ALL TIMES. I AM RESPONSIBLE FOR READING THE PARENT HANDBOOK LOCATED ON THE ROCK WEBSITE.
Parent Signature:
By clicking the box beside “I agree”, you agree that this is valid as your signature. I agree / Date:
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Credit Card Authorization Form
ROCK Summer Enrichment Camp 2017
Credit Card Info:
Visa or Master card:
Credit Card Number:
Expiration Date: /
Security Code:
Billing Info:
Name on Card:
Street Address:
City:
State:
Zip:
Phone Number:
Child/Children Name:
* Please e-mail form to or fax to 469-698-7159
RISD ADMINISTRATION SERVICES/ROCK
1050 Williams Street · Rockwall, Texas 75087 · Telephone 469-698-7032 · www.rockwallisd.com