Curiosity Corner Before and After School Care at Fox Elementary School

3100 St. James Road, Belmont, CA 94002

REGISTRATION FORM FOR GRADES 1-5: SCHOOL YEAR 2018-2019 A separate registration form must be completed for each child.

Child’s Name ________________________________________________________________________Grade _________ DOB _____________ Parent/Guardian #1_________________________________________ Parent/Guardian #2 __________________________________________ Child’s Primary Address _________________________________________________________City _____________________Zip ___________ Parent/Guardian #1 (Hm) ________________ (Wk) ________________ (Cell) ________________ (e-mail)______________________________ Parent/Guardian #2 (Hm) ________________ (Wk) _________________(Cell) ________________ (e-mail)______________________________

Time slots include care on Fox School in-service days, some holidays, and minimum days from 12:20PM.

Monthly Tuition for: Grades 1-5

Tuition Express Electronic Funds Transfer from

Checking Account or Credit Card (MasterCard or Visa only)

by 5th of each month

Personal check, Money Order or cash payments

by 5th of each month Choose 3

days of week

5 days/wk Before School 7:00am - 8:25am

$170o

$180o N/A

5 days/week Before School 7:00am - 8:25am &

After School til 6:00pm

$540 o

$550 o N/A

3 days/week Before School 7:00am - 8:25am &

After School til 6:00pm

$405 o

$415 o

M T W TH F o o o o o

5 days/week After School til 6:00pm

$490 o

$500 o N/A

3 days/week After School til 6:00pm

$370 o

$380 o

M T W TH F o o o o o

Curiosity Corner Admission AgreeementEnrollment in Fox Elementary School is a prerequisite for enrollment in the TK-5th grade Before and After School Child Care program offered at Curiosity Corner. The office at Fox School must clear all applicants to our program. As required by law, the State of California’s Department of Social Services/Community Care Licensing requires the following forms be completed and kept on file by the child’s first day of child care. All forms and records are available for review by Community Care Licensing.

(1) Current School Year Application (2) Admission Agreement (3) Parent Rights (LIC995) (4) Personal Rights (LIC613A)(5) Identification & Emergency Information (LIC 700/mod) (6) Consent for Emergency Medical Treatment (LIC 627)(7) Sunscreen, Media and Homework Form (8) Optional:Tuition Express Authorization Form for EFT Bank Account and Credit Card TransactionsA payment of $75.00 MUST accompany the registration form either by personal check or Tuition Express method using Credit Card (Visa or Mastercard) or Electronic Funds transfer from Checking or Savings Account. To establish a Tuition Express Account please return the Tuition Express Form with your registration form. This fee is NON-REFUNDABLE unless space for the requested time slot is not available. If you are registering additional children in the same household, the registration fee is $50.00 per child.

Families enrolling more than one child residing at the same address will receive a 5% reduction of the monthly tuition for each child.

Children of staff in the Belmont-Redwood Shores School District will receive a 10% discount on tuition. Proof of employment required.

If a rate adjustment is necessary during the school year, parents will be notified at least 30 days in advance.

I understand that the monthly tuition is due on/before the 5th of each month. A late fee of $15.00 is applied to any payment made on/after the 6th of the month including declined credit/debit card payment or declined electronic funds transfer. A $35.00 charge is applied for any returned check. Payer is responsible for advising of any changes to account.

I understand tuition will not be refunded in cases of unanticipated program closure, including but not limited to weather, teacher strike, or local emergency. Students are registered for specific time slots and hours/days may not be substituted. There will be no fee reduction due to student’s absence for any reason.

Changes in enrollment are subject to availability. A 30-day written notice is required for any cancellation or reduction in hours enrolled.

Children who consistently abuse the Discipline Policy of Curiosity Corner will be removed from the program.

I understand that Curiosity Corner does not carry individual medical insurance that will cover my child in case of emergency. All children registered at Curiosity Corner are insured under a Group Accident Insurance Policy.

o I have read the Admission Agreement above and will abide by the policies of Curiosity Corner. I acknowledge receipt of the Curiosity Corner Parent Handbook. (also available at www.curiositycornerkids.com)

___________ ________________________________________ Date Parent/Authorized Representative (print name)

____________________________________________________Parent/Authorized Representative Full Signature

(e-signature accepted)___________ _______________________________________ Date Director’s Signature rev.050318

TUITION EXPRESS ACCOUNT:

I authorize CURIOSITY CORNER to charge the registration fee of $___________ and the recurring monthly fee of $___________to the account

listed on the Tuition Express registration form for child, ______________________________________________.Please PRINT Child’s Name

________________________________ ___________________ Please PRINT Authorized Account Date

Holder’s Name

________________________________Authorized Account Holder’s Signature

(E-Signature accepted)

For the Tuition Express registration form please click here Tuition Express Payment Authorization

Check here to continuing using the form of payment currently on file for your Tuition Express account.

We are excited to offer the safety, convenience and ease of Tuition Express®–a payment processing system that allows secure, on-time tuition and fee payments to be made from either your bank account or credit card.

ELECTRONIC FUNDS TRANSFER AUTHORIZATION FOR BANK ACCOUNT and CREDIT CARD

I (we) hereby authorize (business name) ____________________________________________ to initiate credit card charges to the below-referenced credit card account (Section A) OR, initiate debit entries to my (our) checking or savings account, indicated below (Section B). To properly affect the cancellation of this agreement, I (we) are required to give 10 days written notice. Credit union members: please contact your credit union to verify account and routing numbers for automatic payments. Check with the center for accepted credit card types.

COMPLETE ONE SECTION ONLY

SECTION A (Credit Card, Visa and Mastercard only accepted)

_______________________________________________________________________________________________________Cardholder Name Phone #

_______________________________________________________________________________________________________Cardholder Address City State Zip

_______________________________________________________________________________________________________Account Number Expiration Date

_________________________________________________________________________________________________________________________________ Cardholder Signature Date

SECTION B (Bank Account)

_______________________________________________________________________________________________________Your Name Phone #

_______________________________________________________________________________________________________Address City State Zip

_______________________________________________________________________________________________________ Bank or Credit Union Name Bank or Credit Union Address City State Zip

_______________________________________________________________________________________________________Routing Transit Number (see sample below) Account Number (see sample below)

_______________________________________________________________________________________________________Authorized Signature Date

Automated Payment Processing Safe – Convenient – Easy

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