2024-2025 Summit Creek Academy After-School Registration Form -

Childs Information

Childs Name

Name Called

Address

City

Zip

Birthdate (00/00/0000)

Grade

Teacher

School

If the schools have an unscheduled early release (i.e. inclement weather), my child will:

List all Allegies or enter NONE

List all Medications or enter NONE.

Please select all that apply.

ADD

ADHD

Emotionally, behaviorally, intellectually or physically challenged

Special circumstances/Requests (explain) if none enter NONE

Family Information

Mother/guardians name

Employer's Name

Home Address

City

State

Zip

Cell Number

Home Phone Number

Work Phone Number with Extension

Email

Father/guardian’s name

Home Address

City

State

Zip

Email

Emergency Information

In the case of emergency, please contact the following first

Childs Doctor (Name and Phone)

Childs Dentist (Name and Phone)

Hospital Preference

Insurance Company (Include Policy Number)

Emergency Contacts /Authorized Pickups:

Emergency Contact 1 Name

Emergency Contact 1 Phone

Emergency Contact 2 Name

Emergency Contact 2 Phone

Emergency Contact 3 Name

Emergency Contact 3 Phone

How did you hear about Drop-N-Play?

Important information for you to know:

The weekly tuition of $ 70.00, includes all early release days. The weekly tuition is due regardless of the number of days a student attends during the week, and must be paid even when a student is absent the entire week.
After-school program is not available when schools are closed for holidays or inclement
weather, however the extended all-day program may be available.
All after-school participants will be given a snack upon their arrival to the center.
Students will have daily “homework time”, not to exceed 1 hour. Please note that Drop-N-Play
is a homework first program, if your child does not have homework they should have a book or other educational material with them.
Drop-N-Play does NOT allow cell phones at any time during the afterschool program. Our staff will be happy to allow your child to call his/her parents on our phones when necessary.
Payments are due each Friday prior to the upcoming school week, a $15.00/week late fee will be charged for payments made after the weekly due date. Parents or guardians may make as many advance weekly payments as they choose. Weekly payments will be auto drafted each Friday. Parents will be denied service if weekly payments are not paid on time. A late fee of
$1.00 per minute, per child is charged for each minute a child remains after 6:pm.
Two weeks written notice must be submitted prior to any child’s withdraw from the afterschool program.

Medical Information/Release

If there is a need for emergency medical treatment, 911 will be called. Should an ambulance be needed, parents will be responsible for any costs. Parents will be contacted as soon as possible after contacting 911. Drop -N- Play LLC, employees do not administer medications under any circumstances. I agree that Drop-N-Play LLC, may authorize a physician of their choice to provide emergency care in the event neither I nor our family physician can be reached immediately. I certify my child is in excellent health and physical condition and has no medical, psychological, or mental condition which has not been disclosed to Drop –N- Play LLC, on the registration form.

Release of Liability

I, on behalf of myself, my spouse, and each child designated on the registration form (my “child”), hereby waive and release all rights, causes of action and claims against Drop –N- Play, its Officers, Directors, Agents, and Employees, for any loss, expense, damage or injury suffered by my child during the time my child is visiting Drop –N- Play, including the possible negligence of Drop –N- Play LLC, but excluding gross negligence and intentional misconduct. For good and valuable consideration including but not limited to benefits realized from the utilizing Drop –N- Play as a drop-in center for my child/children for $10.00 and other valuable consideration. I understand that the provision of child care contains risk of injury to persons and damage to property, and that by signing this release I engage Drop –N- Play LLC, to provide temporary childcare for my children at my own risk. I further understand that there is an assumption of risk associated with the use of the center. I have been given an opportunity to inspect the premises of Drop –N- Play LLC, and found that it is safe and satisfactory for my child. I also have been given the opportunity to ask questions and obtain answers to my satisfaction regarding any and all aspects of Drop –N- Play LLC, and this Release. I have received a copy of Drop –N- Play’s Guidelines. By signing this Release, I have not relied on any promises or statements made by Drop –N- Play LLC, or its employees other than those contained in written information (Guidelines) supplied to me by Drop –N- Play LLC. I understand this Release will be kept on file at Drop -N- Play and will continue in effect for this and any future visits my child may make to Drop -N- Play.

I, the undersigned, do hereby state that I have read the above carefully, fully understand the content and consequences of this agreement, and agree to abide by and be bound by the above policies and procedures and release.

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