English Rose Day School Registration Form for 2015-2016 For Office Use Only: Date: _________________ Time: _________________ Today’s Date: ________________ Please fill out one form for each child you are registering Child’s Name: __________________________________________ Birth Date: _________________ Address: __________________________________________________________________________ City: __________________________ State: ______ Zip: _________ Home Phone: _____________ Mom’s Information: Dad’s Information: Name: __________________________________ Name: __________________________________ Cell Phone: _____________________________ Cell Phone: _____________________________ E-Mail: _____________________________ E-Mail: ________________________________ If School Age: Grade entering in September 2015 _______ Name of School attending ____________________________________________________________ Main Program: Time: (for extended care, please see the next page) _____ Infants or Toddlers _____ 3 year old Pre-School (3 years by Dec) _____ 9am to 3pm _____ 9am to 11:30am _____ 12:15 to 2:45pm _____ 9am to 2:45pm _____ 4 year old Pre-School (4 years by Dec) _____ 9am to 11:30am _____ 12:15 to 2:45pm _____ 9am to 2:45pm _____ Extra Year Program (5 years by Feb.2015) ____ 12noon to 2:45pm___ 8:30am to 2:45pm _____ Full Day Kindergarten (5 years by Dec.31, 2014) _____ 8:30am to 2:45pm _____ Kindergarten Enrichment (enrolled in another ½ day Kindergarten program) Your child’s placement in KE at English Rose in either the AM session (8:30am to 11:30am) or PM session (12:15pm to 2:45pm) is dependent on their placement in the public school. All Kindergarten programs are 5 day programs. Days: _____ Mon_____ Tues _____ Wed _____ Thurs _____ Fri Please turn over to continue English Rose Day School Registration Form for 2014-2015 Add-on Programs: _____ Closure Program - Full Time _____ Closure - Per Diem ____Snow Closure ONLY Closure Program - English Rose is open most days when WSD is closed. This includes snow days, but not major Holidays or planned ½ days in the district. Please see Office for full details. _____ Early Bird (6:30-7am) _____ Before School (7am until school starts) _____ After School (dismissal until 6pm) _____ Late Pick-up (6-6:30pm) _____ Lunch Program (Add-on for ½ day students staying thru lunch - 11:30am to 12:15pm) Early-Bird Before School After School Late Pick-up _____ Mon _____ Tues _____ Wed _____ Thurs _____ Fri _____ Mon _____ Tues _____ Wed _____ Thurs _____ Fri _____ Mon _____ Tues _____ Wed _____ Thurs _____ Fri _____ Mon _____ Tues _____ Wed _____ Thurs _____ Fri Registration Fee: $85 for Full Day Kindergarten $45 for all other programs Please read and initial the following: _____ I understand this registration fee reserves a spot for my child in the above-stated program. _____ I understand the registration fee is non-refundable. _____ I understand that the deposit tuition, which is applied to June 2016 is payable no later than April 1, 2015 (new families) or May 1, 2015 (existing families) to guarantee my child’s spot. _____ I understand that the remaining tuition payments will begin August 1, 2015 and continue through April 1, 2016. _____ I understand that I am required to give 30 days written notice if I wish to withdraw my child from the program and receive any refund due me. _____ I understand that I will forfeit my June 2016 tuition deposit if written notice to cancel or withdraw is given after August 1, 2015. _____ I understand that changes to my child’s program must be submitted on a “Change of Program” form (available in the office). Parent Signature: __________________________________________ Date: __________________ Office Use Only: Date registered ____________ Amount Paid ____________ Check # __________ Child/Siblings registered ______________________________________________________________ ___ Contract ___ XL Spreadsheet ___ Ledger ___ Billing ___ Schedule ___ Tracking