<p> @ Inman Middle School</p><p>2016-2017 Before / After School Program Registration Form</p><p>Please print or type . Name of Student: ______LAST , FIRST , MIDDLE</p><p>Address: ______STREET CITY ______STATE ZIP Grade Level: ______</p><p>Name of Parent/Guardian: ______(Will receive program communication) LAST FIRST RELATIONSHIP Telephone Number: HOME (______) ______-______CELL (______) ______-______</p><p>Email Address: ______</p><p>Emergency Contact: ______NAME </p><p>______TELEPHONE EMAIL </p><p>Important Medical Information (allergies, diagnosed health conditions, medications taken every day, etc.): ______Before/After School Fees: </p><p>Before Care is $15 / week or you may pay a $5/day rate for drop in. After School fee is $50/week or $12/day for drop in. All fees must be paid every 2 weeks or monthly by using the Kinderlime Parent App available in the Apple App store or the Google Play store. This app will be used to keep attendance and receive weekly billing info. All fees must be paid 1 week in advance through the Kinderlime App. </p><p>Parents must pay the first 2 weeks in advance of the beginning of before or afterschool care. No exceptions. Children will not be allowed to stay if fees have not been paid accordingly. </p><p>2015 Mental Fitness 21st Century Learning Inc. After School Program @Inman Middle School Page 1 Name(s) of people authorized to pick-up the student: (Attach separate sheet if necessary.)</p><p>______NAME TELEPHONE EMAIL RELATIONSHIP ______NAME TELEPHONE EMAIL RELATIONSHIP</p><p>For additional information on Mental Fitness 21st Century Learning please visit us on the web at www.mentalfitnessatl.org. Please direct any questions or concerns to the Program Director John Childs at [email protected]. Enrollment Policies</p><p>1. Parents must complete the enrollment forms for each child who will attend the program(s). 2. All forms must be completed and returned to the main office before the child can participate in the Before or After School Programs. 3. Children will be allowed to attend the program only after all forms have been completed and returned and the first 2 weeks of program fees have been paid. 4. Each parent must sign up for the Kinderlime Parent App available in the Apple App Store or Google Play Store.</p><p>Participation Agreement: I wish to participate in the Mental Fitness Before / After school program. I agree to follow all the rules of the program. I will do my best to participate with a positive attitude, learn as much as I can, and respect myself, the staff, and other students while following the Inman Middle School student policies at all times.</p><p>______Student’s Signature Date</p><p>I give my consent for my child’s name, voice, photograph, image, or likeness to be used by Mental Fitness 21st Century Learning for the sole purpose of the promotion of Mental Fitness 21st Century Learning and/or Inman Middle School. </p><p>______Parent/Guardian Signature Date</p><p>If you have questions, contact John Childs @ 404-969-6351 office, or [email protected]. </p><p>THANK YOU for registering for Mental Fitness @ Inman Middle School!</p><p>2015 Mental Fitness 21st Century Learning Inc. After School Program @Inman Middle School Page 2 2015 Mental Fitness 21st Century Learning Inc. After School Program @Inman Middle School Page 3</p>