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Quarter 1 Course Offerings
2016-2017 School Year Quarter1 Classes: August 29, 2016 – October 14, 2016
Quarter 1 Registration Deadline: August 26, 2016
Dear Parents: Our After School Enrichment program offers unique opportunities for students outside of the classroom. The purpose of this program is to extend student learning and achievement through teamwork, meaningful hands-on opportunities and performance. Below, you will see a description of each class offered, including the day, grade level, room and cost. The cost funds the instructors for their time, materials used, as well as teacher supervision during study hall (which occurs from dismissal until the start of the enrichment class, if applicable). Prices vary due to the nature of the class and the varying cost for materials. *Please note: Any enrichment may be cancelled due to lack of/low enrollment. All enrichment courses will be released through the front CAFETERIA and must be signed out with the enrichment coordinators. When picking up students, a green car tag MUST be presented. If you do not have a green car tag, you may purchase one from the front office. Otherwise, you must present a valid ID and be in our SIS system. When picking up students, you must park in the parking lot (not car loop) and walk in to physically sign out your student. These procedures are in place for the protection of all of our students and your cooperation is necessary and appreciated. Please be on time when picking up from enrichments. After 15 minutes, students will be signed in to After Care and be charged for the day. In the event that an enrichment needs to be cancelled for the day, the teacher, vendor or enrichment coordinator will contact you with as much advance notice as possible. We try to ensure that all classes are taught as scheduled, but occasionally emergencies do come up. If a class is cancelled by the instructor, a make-up class will be offered prior to the end of the quarter. If a class falls on a holiday, there will be no make up for that class. Along those lines, we do take attendance at every class meeting, and if your child will not be staying for an enrichment, please contact Mr. Laird and he will forward that information on to the instructors. All checks are to be made payable to RCSSL unless you are signing up with one of our outside vendors. Vendors indicate who to make checks payable to in their class description. If paying with cash, please separate money between teacher offered enrichments and vendor offered enrichments. If you sign up for more than one enrichment, list only one enrichment per application form. If you have any questions, please do not hesitate to contact me. Thank you, and we look forward to another great year! Scott Laird ASE Coordinator [email protected] 772-344-5982
After School Enrichment
Do you have a guitar laying around that you are dying to learn how to play? Come hang out with Mr. Jackson, an experienced
musician and guitar player. All students are welcome regardless of ability level. Students will learn fundamentals and songs
designed to improve playing. Continuing students/more experienced students will learn chord progressions and improvisation.
Student will need to provide their own guitar. We recommend Guitar Center or Music Man Inc (both located in PSL) if you are
looking to purchase or rent an instrument.
Class Name Grade
Levels
Day & Time Maximum
Enrollment
Quarter Price Location Instructor(s)
Guitar 3-8 Tuesdays
3:45-4:45
Open $65 334 Mr. Jackson
Renaissance Chorus K-8 Mondays
3:45 – 4:45
Open $65 110 Ms. Gerheart
Do you love to sing? Would you like to improve your vocal technique and ability? Then the Renaissance Chorus is the place for you.
Whether you have been singing for years, or are just getting started, you will expand your talents and create beautiful harmony with
our group. The chorus will perform at the Enrichment showcase in December*. *Students will need to reregister for Quarter 2.
Ballet & Acro K-5 Fridays
3:00 – 4:00
Open $85 222 Mrs. Adela
Balletfest Dance Academy is very pleased to be in charge of the ballet and acrobatic classes at RCSSL. Registered students will be
invited to perform in our December and June recitals at our Academy (not mandatory, but it is a great opportunity). Students will need
to wear comfortable clothing. (For those interested, Mrs. Adela will be able to provide ballet shoes, leotards, tights, etc. at a great
price.) This group will perform at the Enrichment showcase in December. Check us out online at www.balletfest.com Please note
that this class is run by an outside vendor. Checks should be made payable to Ballet Fest Dance Academy. .
Dancing Divas K-8 Mondays &
Thursdays
3:45 – 4:45
25 $65 332 Ms. Toney
If you feel like dancing, c’mon! During this class, you will learn and develop all of the aspects of a color guard dancer. Time will be
spent learning basic technique, choreography and team sportsmanship! The group will perform at the Enrichment Showcase in
December*. *Students will need to reregister for Quarter 2.
Glee Club 6-8 Thursdays
3:45 – 4:45
16 $65
New
Members
Only
310 Mr. Laird
The Glee Club is the place to be if you have a love of performing. Members will get the full show choir experience, combining
singing, acting and dance. Membership is limited to 16 people and is by audition only. Anyone in 6th thru 8th grade is invited to try
out. Those interested should speak to Mr. Laird in room 310 prior to filling out an enrichment form to set up an audition time. The
group will perform at the Enrichment Showcase in December*. *Students will need to reregister for Quarter 2.
Step Team Jr. K-5 Fridays
3:45 – 4:45
25 $25 308 Ms. Gabby
The team will perform a unique art form that originated in Africa. Stepping is a form of percussive dance in which the participant’s
entire body is used as an instrument to produce complex rhythms and sounds through a mixture of footsteps, spoken words, and
hand claps. The group will perform at the Enrichment Showcase in December*. *Students will need to reregister for Quarter 2.
Performing Arts
Class Name Grade
Levels
Day & Time Maximum
Enrollment
Quarter Price Location Instructor(s)
Goju-Karate Do K - 8 Tuesdays
3:45 – 4:45
25 $80 Cafeteria Shihan Mic Norcia
Students will learn a number of things dealing with self-defense, anti-abduction and dealing with bullying. They will strive to build
confidence, discipline, motivation and a proper attitude towards schoolwork. They will learn to be accountable for their actions...at
school and outside of school. Their grades must stay up, or they cannot train in my Dojo. Shihan Mic Norcia ****Must complete a
release form before participation****. (Form found before the registration form.) *Please note that this class is run by an
outside vendor. *Checks should be made out to Goju Karate.
Softball 5-8 Tuesdays
3:45 – 4:45
Open $70 PE Field Ms. O’Brien &
Ms. Rolle
Calling all students with a love of the game! Boys and girls alike are welcome on the field to work on their skills and to play some
friendly games. Comfortable clothing and sneakers are encouraged. Students should bring their own gloves if they have them.
Leader Cheer
Leader Cheer
1 - 2
3 - 4
Tuesdays
3:15 – 4:45
JV – 12
Varsity - 15
$90
$90
PE Field
PE Field
Ms. Meltzer
Ms. Meltzer
LeaderCheer offers young athletic students (JV 1-2 grade, Varsity 3-4 grade) the opportunity to learn the sport of cheer from
Beginner Level through Level2. Knights cheer teams who register for QTR 1 and QTR 2 will perform an exhibition routine on
Friday December 16th 6:30pm at LeaderCheer gym (540 NW Mercantile Road PSL - across from the Mets stadium). Students will
learn school spirit, leadership and teamwork! Teams receive practice shirt and cheer bow. Practices will be every TUESDAY 3:15-
4:45. Cost is $90/Qtr (Not avail 4th qtr) Cheerleaders who cheer all three quarters will receive a discount for the 3rd Qtr. ($90 1st
Qtr, $90 2nd Qtr, $75 3rd Qtr) Attendance at practice is expected. Both JV and Varsity teams have been full in the past so DON’T
wait to sign up! This will be the 4th year Knights have had cheer teams for their school! It has been truly exciting to watch these
young cheerleaders grow from beginner cheerleaders to competitive cheerleaders over the years! Through positive and encouraging
instruction from new and returning LC coaches, students will learn to Cheer for Fun, Lead for Life with LeaderCheer! Go Knights!
*Please note that this class is run by an outside vendor. Checks should be made payable to LeaderCheer.
Playball K - 4 Thursdays
3:15 – 4:30
Minimum
Of 12
$90 PE Field Coach Frank
Playball introduces students to a wide variety of sports: hockey, baseball, basketball, tennis, soccer, and flag football. Playball is
taught in a safe, energetic, creative and fun atmosphere that promotes learning. Positive reinforcement, specialized coaching
techniques and the use of imagery allow us to nurture students on the physical, social and emotional levels. For more information
visit www.coachingplayball.com/playball. *Please note that this class is run by an outside vendor. *Checks should be made
payable to Playball Treasure Coast. CLASSES DO NOT BEGIN UNTIL 9/3!!
Ball Games K-5 Mondays
3:45 – 4:45
Open $65 Carloop Ms. Babos
Students in this class will be exposed to various ball games such as soccer, basketball, volleyball and dodgeball. While learning the
basics, students will also be working on teamwork and sportsmanship. This is a great opportunity to make some new friends and
stay active outside!
Basketball
Conditioning
5-8 Tuesdays &
Fridays
3:45 – 4:45
Open $50 Carloop Coach Perez
Training for basketball is a yearlong commitment. The preseason training period typically starts at the beginning of September and
runs through mid-October. A strength and conditioning coach working with basketball players has the responsibility of designing a
program that will make them better athletes. Flexibility, conditioning, speed, quickness and agility, along with strength and power
are all worked on in the program to prepare students for basketball try outs in October.
Athletics
Cross Country 5-8 Mondays &
Thursdays
3:45 – 4:45
Open $50 Meet in 311 Coach Perez
Cross Country is a competitive team sport that is traditionally offered in the fall that incorporates training and group running.
Teams are made up of five or more athletes who run together to compete against other teams. Students typically run across grassy
fields, wooded paths, and hills. Some courses even have small streams and log jumping to make it interesting. The benefit of a cross
country team is that all athletes get to compete and participate in every meet.
Class Name Grade
Levels
Day & Time Maximum
Enrollment
Quarter Price Location Instructor(s)
G.L.A.M.
G.L.A.M
2 – 5
6-8
Mondays
3:45 – 4:45
Tuesdays
3:45 – 4:45
Open
Open
$25
$25
107
107
Ms. Hughes
Ms. Hughes
What parent doesn't want to give their daughter the opportunity to build self-confidence? Girls Learning About Maturity (G.L.A.M)
is a new and exciting group being introduced to RCSSL for the 2016-2017 school year. This uplifting organization will focus on
promoting positive self-esteem, encouraging leadership skills, and building a sisterhood. Through community involvement and
female empowerment your child will experience a first look at what it takes to be positive role model.
Homework Helper
Homework Helper
K – 8
K- 8
Mondays,
Thursdays
3:45 – 4:45
Tuesdays
3:45 – 4:45
25
25
$25
$25
308
332
Ms. Gabby
Ms. Toney
In this class, students will have the opportunity to work on assignments that they have been given, as well as receive additional
help. This is a great opportunity for students who may need a little extra motivation and encouragement. Students will have access
to computers and any other resources they may need to complete the assignments that they have been given
Write and Illustrate
A Picture Book
3-7 Tuesdays
3:45 – 4:45
20 $80 130 Mrs. Mangual-Price
Explore the art of creative writing and illustrate your own book! Students will learn how to organize, write and illustrate their very
own picture book. Join this published writer/teacher led enrichment and immerse yourself in the adventure of writing and
illustrating your own story. Come join the fun!
Cooking for Teens 6-8 Thursdays
3:45 – 4:45
Open $80 +
$20 for
supplies
305 Ms. Philip
Do you want to be the next Gordon Ramsay or Rachael Ray? They all had to start somewhere! Come join us in Cooking for Teens.
We will explore different foods, and how to prepare them in a fun and healthy way! Who knows, we may even find the next Food
Network Star!
Miscellaneous Activities
Knight’s News
School Paper
4 - 8 Mondays
3:45 – 4:45
10 $65 211 Ms. Kircheis
Renaissance Charter School of St. Lucie is proud to be publishing their very own newspaper this year. Students will learn the ins
and outs of the paper industry and be able to interview, write, edit, and layout their own articles for the Knights News! Our
publication will go to print quarterly.
Fun Science K - 5 Thursday
3:45 – 4:45
16 $89 132 Ms. Babos
Fascinating, fun, hands-on science experiments to enrich your mind. In this class, you will learn about and do experiments
concerning Earth Science (volcanoes, geysers), weather (rainbows, snow/ice), life (animals), and so much more! All supplies are
covered in the cost of the course.
Mad Science 6 - 8 Mondays &
Tuesdays
3:45 – 4:45
Open $65 301 Ms. Calderon
Put on your lab coat and safety goggles because it is time to put your energy into science! Be prepared to explore the world of
STEM (Science, Technology, Engineering, and Mathematics) to create new and innovating inventions in a classroom lab. We will
explore scientific strategies to create an engaging environment for students to become lifelong learners!
Monet Jr. Oil Painting 3 - 7 Thursdays
3:45 – 4:45
10 $80 + $20
Supplies
130 Mrs. Mangual-Price
Club Monet Jr. will empower students to explore their creativity and help develop their affinity for the fine arts in this hands-on oil
painting class. Students will learn and practice basic skills for oil painting. Students will also have the opportunity to critique and
reflect on their work. The $20 materials cost covers supplies the students will use and keep.
Multicultural
Snack Time
K-5 Tuesdays
3:45 – 4:45
Open $95 132 Ms. Babos
Do you have an interest in cooking? This is the group for you. In this class, students will be making and enjoying different unbaked
snacks from many cultures from all over the world. We will be making famous European, American, and African dishes! All
materials are covered in the course cost.
Kitchen Science K-5 Tuesdays
3:45 – 4:45
10 $50 119 Ms. Banat
In Kitchen Science, students will be given opportunities to explore science through hands on activities. Some of these activities will
be discovering states of matter through making ice cream, and learning about density by making juice. Our young chef/scientists
will discover that there is science everywhere they go!
Bricks 4 Kidz K-5 Thursdays Open $55 124 Shana Giles
3:45 – 4:45
Do you enjoy building with LEGO? If you do...this is the program for YOU! We will be building models based around some of
our favorite amusement rides; learning the history and mechanics behind them. Each student will get to build their own mini-
figurine the first week of class to play with during building time and creative building time. The students will take these home the
last week of class. *Please note that this class is run by an outside vendor. Checks should be made payable to Bricks4Kidz.
After School Enrichment Important Dates 2016-2017 School Year
8/15-8/26 Q1 After-School Enrichment Registration Period
8/29 Q1 After-School Enrichment Starts
9/5 No ASE - No School (Labor Day)
9/23 No ASE - No School (Teacher PD Day)
10/12 No ASE - No School (Fall Holiday)
10/14 Q1 After-School Enrichment Ends
10/17-10/21 No ASE – Make-up Week
10/10-10/21 Q2 After-School Enrichment Registration Period
10/24 Q2 After-School Enrichment Starts
St. Lucie Knights Male
Youth Group
5-8 Saturdays
9:30 – 10:30
Open $25 Meet in
Front
Lobby
Coach Perez
The goal for the St Lucie Knights Male Youth Group is to raise the aspirational levels of our youth by exposing these promising
students to practical leadership through club oriented responsibilities. The objectives will be:
1. To inspire service in the public interest through the cultural enrichment and character development of young males between the
6th to 8th grade.
2. To develop leadership skills while monitoring, encouraging, and rewarding outstanding academic performance.
3. To refine self-image, self-esteem, social skills, and environmental awareness.
4. To assist parents by providing opportunities for their child to discuss career options with successful professionals
5. To afford the less fortunate youth with sponsored entertainment and culture enrichment.
6. To inform youth of the value of higher education, assistance available for continued educational pursuits, scholarships, loans,
professional counseling, and fellowships
Key: Registration Periods Quarter Start/End Dates Showcase Dates ASE Cancellation Dates
Course Breakdown by Day
Course Grade Cost Location Instructor
Monday
Dancing Divas (Mon & Thurs) K-8 $65 332 Ms. Toney
Renaissance Chorus K-8 $65 110 Ms. Gerheart
Ball Games K-5 $65 Carloop Ms. Babos
Knights News Newspaper 4-8 $65 211 Ms. Kircheis
Mad Science (Mon & Tues) 6-8 $65 301 Ms. Calderon
G.L.A.M. 2-5 $25 107 Ms. Hughes
Homework Helper K-8 $25 308 Ms. Gabby
Cross Country (Mon & Thurs) 5-8 $50 311 Coach Perez
Tuesday
Guitar K-8 $65 334 Mr. Jackson
Goju-Karate Do K-8 $80 Cafeteria Shihan Mic Norcia
LeaderCheer 1-2,3-4 $90 PE Court Ms. Meltzer
Softball (Coed) 5-8 $70 PE Field Ms. Rolle & Ms.
O’Brien
Multicultural Snack Time K-5 $95 132 Ms. Babos
G.L.A.M. 6-8 $25 107 Ms. Hughes
Write & Illustrate a Picture Book 3-7 $80 232 Mrs. Mangual-Price
Mad Science (Mon & Tues) 6-8 $50 301 Ms. Calderon
Kitchen Science K-5 $50 119 Ms. Banat
Homework Helper K-8 $25 322 Ms. Toney
Basketball Conditioning (Tues & Fri) 5-8 $50 Carloop Coach Perez
Thursday
Glee Club 6-8 $65 310 Mr. Laird
Dancing Divas (Mon & Thurs) K-8 $65 332 Ms. Toney
Playball K-4 $90 PE Field Coach Frank
Fun Science K-5 $89 132 Ms. Babos
Monet Jr. Oil Painting 3-7 $80 +$20 232 Mrs. Mangual-Price
Homework Helper K-8 $25 308 Ms. Gabby
Bricks 4 Kidz K-5 $55 122 Ms. Giles
Cooking for Teens 6-8 $80 + $20 305 Ms. Phillip
Cross Country (Mon & Thurs) 5-8 $50 311 Coach Perez
Friday
Step Team Jr. K-5 $25 308 Ms. Gabby
Ballet and Acro K-5 $85 222 Ms. Adela
Basketball Conditioning 5-8 $50 Carloop Coach Perez
Saturday
St. Lucie Knights Male 5-8 $25 Lobby Coach Perez
Youth Group
Additional Opportunities for Enrichment Coming Soon!
Mathematical Olympiad
Students in grades 4 – 8 will have the opportunity to join the Math Olympiad team. Ms. Phillip will be
leading this group through practice sessions and competitions at the national level. There are prizes and
trophies to be won for showing off how analytical you are! There are a limited number of spots on the
team, and information will be sent home with interested students. Positions will be filled on a first come-
first served basis.
To request information, please contact Ms. Phillip at [email protected]
Science Olympiad
The goal of Science Olympiad is to improve the quality of science education through competitions
similar to sporting events. Just as students are motivated to compete in various sporting activities,
students compete as a team against other schools in 23 different events that range the spectrum of
science subjects. What's more, our events are inquiry based and have been designed to correlate with
the National Science Education Standards and the Sunshine State Standards. We are the only science
competition listed in the national standards as an exemplary implementation of inquiry and assessment.
More information coming soon.
To request information, please contact Ms. Calderon at [email protected]
Odyssey of the Mind
This is an international educational program that provides creative problem-solving opportunities for
students from kindergarten through college. Team members apply their creativity to solve problems that
range from building mechanical devices to presenting their own interpretation of literary classics. They
then bring their solutions to competition on the local, state, and World level. Thousands of teams from
throughout the U.S. and from about 25 other countries participate in the program.
To request information, please contact Ms. Eltman at [email protected]
Middle School Step Team
Keep an eye out for audition info coming soon!
Gojushinkai Karate INC
HOLD HARMLESS AND
LIABILITY RELEASE AND WAVIER AGREEMENT
____________________________________________________________________/_______________
___
Last Name First MI Age Date of Birth
____________________________________________________________________________________
___Address City State Zip
____________________________________________________________________________________
___
Email Address
_______________________________________________________________________________
Phone - Area Code Date
I, ___________________________________, have voluntarily submitted my application for registration
as a student or for my student child _____________________ in the Gojushinkai Karate Inc. program.
By submitting the application for membership, I certify that I am fully aware of and understand the
inherent dangers in the participating in activities involving martial arts, and of the basic safety rules, and
procedures, including, but not limited to, promotional rank testing, summer camps, after school karate
program and tournaments which I may enter.
I understand and agree that the operator of the school, the instructors, owner of the school building, or
any other student, will not be responsible for my safety, nor will any of these parties or individuals serve
as a guardian of myself or my child’s safety.
I understand and agree that neither the operators of the school, Gojushinkai Karate Inc. its owners, the
instructors, or any other student, their agents or assigns, or any other individual or entity associated with
Gojushinkai Karate Inc. may be held liable in any way for any occurrence or event in connection with
my membership or participation in tournaments or camps which may result in injury, death or any and
all damages to me or to my family, descendants, heirs or assigns or any other individual or entity
associated with Gojushinkai Karate Inc. may be held liable in any way for any occurrence or event in
connection with my membership or participation in tournaments or camps which may result in injury,
death, or any and all damages to me or to my family, descendants, heirs or assigns.
I understand and agree that in consideration of being allowed to be a student in this program, including
tournaments or summer camps, I hereby personally assume any and all risks involved in connection with
the same; and furthermore, I release forever the aforementioned individuals and entitles and any other
individual or entity associated with this program, for any harm, injury or damage that may occur to me/
my child or befall me/ my child while I am a student in this program, including any and all risks
connected therewith whether foreseen or unforeseen, including any risks created and/or harm caused by
any negligent act (excluding gross negligence or recklessness behavior) or acts of any or all of the
above-mentioned parties. Furthermore, I will hold harmless the above-mentioned parties from any claim
by me, my family, my estate, my heirs, my personal representatives or their assigns, arising out of my
participation in the program, tournaments or camps.
I further state that I am of lawful age and legally competent to sign this agreement and that my
signing this agreement is my own free act (unless a parent or legal guardian signs this). I also understand
and agree that the terms herein are contractual, and they are not a mere recital or simply for information
purposes.
I have read, and understand, and fully informed myself of the contents of this agreement. I
assume my own responsibility for my physical condition and capability to perform under the program,
tournaments or summer camps in which I may participate.
__________________________ _________________________
Signature Date
___________________________ ___________________________
Please print name Type of Identification Produced
TO BE SIGNED IF ABOVE IS EXECUTED
BY PARENT OR LEGAL GUARDIAN
In consideration of the aforementioned activities, and as parent or legal guardian of the minor
named above, I, on behalf of said minor, agree to indemnify and save harmless Gojushinkai Karate
Inc., the organizers of the program, the instructors, tournament officials, camp directors, other
contestants in the programs or tournaments, or their agents or assigns, against any claim for damages,
compensation or otherwise on the part of said minor or his or her heirs, executors or administrators and
to reimburse or make good any loss or damages or costs that any of the above parties may have to pay if
any litigation arises on account of any claims made by said minor or anyone in his/her behalf.
Furthermore, I release any claim or cause of action that I may personally have as parent or legal
guardian resulting from any such injury or death to said minor.
__________________________ __________________________
Signature of legal guardian Date
___________________________ ___________________________
Please print name Type of Identification Produced
Quarter 1 Registration 2016-2017 School Year
Quarter 1 Classes: August 29, 2016 – October 14, 2016
Quarter 1 Registration Deadline: August 26, 2016
Enrichment Class_________________________________________________________________ Price _______ Day _____________
(One form per class, one check per class)
Student Name __________________________________________________________________ Birth
Date_______/_______/_______
Homeroom Teacher Name_________________________________________________Homeroom Room #___________ Grade
_______
Parent/Guardian Name _______________________________________________________ Phone # _________________________
Parent/Guardian Name _______________________________________________________ Phone # _________________________
E-Mail ______________________________________________________________________________________________
Emergency Contact (other than those listed above) _________________________________________________________
Phone # __________________________________ Relationship To Student ____________________________________
Is the student registered for After Care? _______ Does the child have permission to walk/ride bike home? ________
Allergies or pertinent information regarding the student:
______________________________________________________________________
The following people have permission to pick up my student(s) in the event that I am unable. They understand that they must show
valid ID.
Please Print.
1._____________________________________________________________
2._____________________________________________________________
3._____________________________________________________________
4._____________________________________________________________
*Please make sure there is only one form and one check for each enrichment. Please see class descriptions for outside vendor check
information. All students should consider themselves “accepted” into classes unless contacted otherwise by teachers. Enrichment programs
are non-refundable, except for long-term illness or the cancellation of a program, due to low enrollment. Attach payment (checks made
payable to RCSSL are preferred for non-vendor run classes) in an envelope and turn in to the homeroom teacher or office. Any check that
bounces will incur a $25 fee. Please make note that the registration deadline is August 26, 2016. Classes begin August 29, 2016 and
end October 14, 2016. There is no ASE on teacher planning days, school holidays, nor days when the school district cancels after-school
activities due to severe weather alerts. Parents must PARK (not in the carloop) when picking up student. ALL PARENTS MUST
PRESENT A GREEN CARLOOP TAG WITH THEIR CHILD’S NAME IN ORDER TO SIGN OUT. Students who are not picked
up within 15 minutes of enrichment ending will be signed in and charged for Aftercare. If you have any additional questions or concerns
please contact Mr. Laird via e-mail at [email protected].
I understand and agree to the above guidelines.
Parent/Guardian Signature: ________________________________________________________ Date:________________
ASE Teacher use only! (One copy for teacher, one copy for After-School Enrichment Coordinator)
Cash _____ Check #_________ Total Amount $ ________
Enrichment Coordinator Signature__________________________________________ Date_______________