Dolphin Club After School Program

DOLPHIN CLUB AFTER SCHOOL PROGRAM REGISTRATION AND PERMISSION FORM 2014-2015 John D. Philbrick School ● 40 Philbrick St. ● Roslindale, MA 02131

Please return completed this form either to Diana Hart or Lorraine Seto Questions, advice, comments, etc., to [email protected] ● [email protected] Program will start on Thursday, September 4th. K2 will start on Monday, September 8th.

Student: ______Grade: ______

Date of Birth: ______Age as of 9/4/14: ______Gender: (Circle One): M F

Parent / Guardian 1: ______

Address: ______City/State/Zip: ______Best Phone Number Between 3:00 PM and 6:00 PM (Please Circle One) ______Cell Work Home

Other Number(s) ______

Primary E-Mail for Notices: ______

Parent / Guardian 2: ______Best Phone Number Between 3:00 PM and 6:00 PM (Please Circle One) ______Cell Work Home

Other Number(s) ______

Secondary E-Mail for Notices: ______

People I Authorize to Pick Up My Child: Relationship Phone Name: ______To Child: ______Number(s): ______Relationship Phone Name: ______To Child: ______Number(s): ______Relationship Phone Name: ______To Child: ______Number(s): ______

Health: Does your child have any health concerns we should be aware of? Please list any allergies, specialized dietary needs, physical needs, prescription drugs, etc., which might need our attention during the afterschool program.

______

If you would like to discuss your child’s health concerns with us confidentially, please call Diana Hart at 617-833-9142 or Lorraine Seto at 617-549-5211. Student’s Schedule: Please fill in your student’s schedule.

Full Time:  Monday through Friday

Part Time - Check off Days:  Monday  Tuesday  Wednesday  Thursday  Friday

Drop In:  Notes: ______

Full Time (5 Days per Week): $240 per Month Part Time Weekdays monthly fee: $55/1 day $110/2 days $165/3 days $220/4 days Drop In: $20 per Day ● Drop In Payment is Due at Pick Up on that Day ● No Drop Ins will not be allowed without receipt of this Completed and Signed Registration and Permission Form

For a sliding scale we adhere to the Massachusetts State Guidelines for Childcare Proper income documentation must be submitted to Amy Sprott, Principal

Payment is due in advance on the first day of the month. You will be billed for days your child is scheduled to participate even if they do not attend due to sickness, weather cancellations or other circumstances.

Please enclose first month’s payment with this form.

If payment is not received when due, a $5 per week late charge will be assessed. Payments past due over 30 days will result in suspension from the program.. You will be charged $25 for any returned checks. Late pick ups after 6:00 PM will be charged $1 per minute.

I authorize my child to participate in the Dolphin Club After School Program and I agree to the terms of this contract. I understand that the Boston Public Schools Code of Conduct applies to this program.

Parent / Guardian Signature:______Date: ______