1281 Main Street, Dublin, NH 03444 (603) 563-8508

Participating Agreement for After School Services

Registration Information:

2014-2015

Childs Name: _______________________________________________________________________ Mothers Name: _______________________________Fathers Name:___________________________ Mailing Address:______________________________________________________________________ Telephone (day): ______________________________Telephone (eve):__________________________ E-Mail address: ____________________________________________ Hours an !ees: After s hool are !ill "e provided "et!een the ho#rs of $:$% &M and ':$% &M at a flat rate of ()'*%% per day* M-F ($%%+month or M+,+F ()-%+month or T+T. ()/%+month ( ir le one)

Contracted services are billed regardless of attendance, as this space is reserved for your child. "he Parent#$uar ian Agrees "o: &ay an ann#al non-ref#nda"le registration fee of (/'*%% per hild or ($'*%% per family* Registration fee waived for children enrolled in the preschool day program or the before school program. Complete and s#"mit to the pres hool a hild health form0 #pdated ann#ally to age '0 an emergen y information form0 and a general permission form* Call "y $ &M if yo#r hild !ill not "e oming for the day* &rovide alternate are in ase of emergen y for instan es !hen the pres hool is #na"le to are for yo#r hild !itho#t advan e noti e* &rovide alternate are in ase of a ontagio#s illness or fever0 and for sno! days and emergen y losings* 1erve as a ooperative parent "y assisting the tea hers and e2e #tive 3oard !ith the operation0 maintenan e d#ties0 and f#ndraising a tivities to a hieve the goals of the pres hool as o#tlined in the "yla!s* 4ive t!o !ee5s noti e if yo# plan to disenroll yo#r hild* %perating Policies: &e ication: 6f yo#r hild re7#ires the administration of an' medi ation "y the pres hool staff0 in l#ding pres ri"ed medi ation as !ell as over the o#nter medi ines0 !e !ill re7#ire (oth a !ritten a#thori8ation signed "y the parent+g#ardian as !ell as a !ritten note from the hilds li ensed medi al pra titioner spe ifying the name of medi ation0 dosage0 times to "e given0 and for ho! many days* All medi ation m#st "e in its original ontainer0 la"eled !ith hilds name and date* "uition: T#ition is divided into ten monthly installments that !ill "e "illed on the /'th of the prior month and d#e "y the )st of the month* )ate "uition: A (/' late fee !ill "e iss#ed to families !hose t#ition payments are not re eived "y the )st of the month and yo#r hild+ hildren !ill not "e a"le to attend s hool #ntil yo#r a o#nt is paid in f#ll*
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%perating Policies *ont+: *hanges to Participating Agreement: T!o !ee5s noti e is re7#ired for all hanges* 9p to t!o hanges per year per a o#nt are allo!ed0 !ith an administrative fee of ()% per hange* There is a (/% per hange fee for any additional hanges* Refun s: :ef#nds !ill not "e made for a"sen es0 illness0 sno! days or other emergen y losings* :ef#nds for t#ition already paid !ill only "e given !ith t!o !ee5s noti e in !riting to the treas#rer* A itional "ime: The rate for pre-approved additional time is (;*%% per ho#r* ,ounce *hec-s: There !ill "e a (/' fee applied for ret#rned he 5s< m#ltiple o #rren es !ill re7#ire all f#t#re payments to "e made in f#ll in ash* ,ehavior: =C& reserves the right to dismiss any st#dent d#e to "ehavior iss#es (see 3ehavioral &hilosophy)* S.itching: &arents may not s!it h attendan e days ("ring a M,F hild on T#esday instead of Monday0 et *)* 6f there is spa e availa"le0 a parent may add an additional day at the additional time rate0 permission from a tea her is re7#ired and /> ho#rs noti e is appre iated*

__________________________ Parent Signature

__________________________ /ate Signe