ASPIRE Plus Registration Form


PROGRAM INFORMATION 

Program Guidelines 

  • The first day of the program will be the first day of school in August 2017 and will continue until the last day of school in June 2018, as long as there are enough students enrolled to secure the required staff.
  • ASPIRE PLUS students are not held to any strict attendance or early release policy requirements.
  • The Student Code of Conduct enforced during the school day at your child’s school will also be enforced during the after school program and students may be dropped from the program for unacceptable behavior.
  • Students may travel in order to participate in off-site field trips and/or KidsPlay sports leagues and parents/guardians will receive sufficient advance notice and schedules of such off-site activities.
  • One of the parents/guardians is required to attend a Parent Orientation at the beginning of the school year. Failure to attend will result in your child’s dismissal from the program. The Site Coordinator will announce dates early in the school year for your child’s school.

Equal Opportunity

LEARN is an Equal Opportunity Non-profit Organization committed to providing all employees and program participants an environment free of discrimination and harassment regardless of race, color, religion or belief, national, social or ethnic origin, sex (including pregnancy), age, physical, mental or sensory disability, HIV status, sexual orientation, gender identity and/or expression, marital, civil union or domestic partnership status, past or present military service, family medical history or genetic information, family or parental status, or any other status protected by the laws or regulations in the locations where we operate.

 

STUDENT INFORMATION

What school will your son/daughter attend during the 2017-18 school year?:   

Have you already enrolled your son/daughter for 2017-18 school year at th e school you selected above?:   

Student Name:   

Gender:   

Grade:   

Date of Birth:   

Age:  

Student Address:   

Home Phone Number:   

Mobile Phone Number:   

Student Email:   

 

PARENT/GUARDIAN INFORMATION

Parent/Guardian #1 Name:   

Parent/Guardian #1 Address:   

Parent/Guardian #1 Home Phone Number:   

Parent/Guardian #1 Mobile Phone Number:   

Parent/Guardian #1 Email:   

Parent/Guardian #2 Name:    

Parent/Guardian #2 Address:   

Parent/Guardian #2 Home Phone Number:   

Parent/Guardian #2 Mobile Phone Number:   

Parent/Guardian #2 Email:   

 

STUDENT HEALTH HISTORY & INFORMATION

Medications – If your son/daughter is required to be administered medication during program hours, an “Authorization to Medicate” form must be completed and submitted to LEARN. The form requires the physician’s signature. If you list any medications here, you will be emailed a printable copy of the form. A paper copy of this form can also be obtained from the Site Coordinator. Please follow the completion instructions on the form. : 

Medications:  

Medical Conditions:  

Allergies: 

Primary Care Physician’s Name:   

Primary Care Physician’s Phone Number:   

Health Insurance or Health Plan Provider:   

Health Policy/Plan Number of Member ID:   

 

EXPLANATION OF FEES AND BILLING POLICY

The ASPIRE PLUS program is a fee-based program with a nominal, monthly fee of approximately $120 per student. The monthly fee will vary month-to-month, based on the number of program days of operation.  Fees and program regulations are reevaluated on an periodic basis and may be subject to change.

Explanation of Fees

  1. BASE FEE: The program begins immediately at the time of your child’s dismissal from school. The daily base fee for the first 3 hours of program is $6.00.
  2. EXTENDED CARE FEE: An additional $6.00 extends the program beyond 3 hours for a given day, but no later than 6:00pm.
  3. LATE PICK-UP FEE: Any pickup after 6:00pm is considered late and is subject to a $1.00 per minute late pick-up charge that accrues for every minute after 6:00pm until you pick-up your child.
  4. LATE PAYMENT FEE: A late payment fee in the amount of $15.00 will be assessed if payments are not received by the due date specified on the Invoice, Statement and/or Billing & Payment Calendar (whichever date is later).
  5. FIRST-MONTH PRORATION: If your child joins the program in the middle of the month, we will prorate the fees for the first month of enrollment only.
  6. NO REFUNDS FOR UNUSED DAYS/TIME: No refunds will be given for any hours or days unattended within a service month.

Acknowledgement of Fees

Billing Policy

  1. ASPIRE PLUS is a fee-based program requiring that the monthly Base Fee be paid in advance of the month of service (pre-payment).
  2. After the month of service, a statement will be provided showing paid/unpaid Base Fees, Extended Care Fees, Late Pick-Up Fees, and Late Payment Fees, if any.  The Statement will also show all payments/credits posted during the statement period.
  3. Payments will be due by the specified date on the prepayment calendar provided to the Parent/Guardian at the mandatory Parent Orientation.
  4. No refunds will be given for any hours or days unattended within a service month.
  5. Pre-payment for the entire month of service is required, except for the first month of attendance.
  6. Pre-payments will not be accepted for the following month if your account has an outstanding balance.  Your child will not be allowed to continue in the program if outstanding fees and/or prepayments are not paid on the date specified on the Invoice, Statement and/or Billing & Payment Calendar (whichever is later).

Acknowledgement of Billing Policy

INDICATE PREFERRED HOURS OF PARTICIPATION IN THE PROGRAM 

In order for us to best serve your son/daughter in the program, please indicate the hours you regularly want your child to participate in the ASPIRE PLUS program. Remember that any day your child stays beyond the standard 3 hours will be charged at double the daily rate, and that if you do not pick up your child before 6:00 PM, you will be charged a $1 per minute late fee for every minute after 6:00 PM until you pick-up your child.

Monday Start:   

Monday End:   

Tuesday Start:   

Tuesday End:   

Wednesday Start:   

Wednesday End:   

Thursday Start:   

Thursday End:   

Friday Start:   

Friday End:   

 

AUTHORIZATION FOR RELEASE OF STUDENT

Students in Grades TK – 5 will not be released to walk home at program-end and must be picked up by an Authorized Adult listed on this form. Students in Grades 6 – 8 may be released to walk home at program-end if a parent/guardian authorizes LEARN staff to do so. Such authorization must be provided on this form.

Initials of Parent/Guardian – My son/daughter is in Grade 6, 7 or 8 and therefore eligible to be released to walk home alone with my written authorization. My initials below authorize LEARN personnel to release my son/daughter when the program ends so he/she can walk home alone. If this field is left blank and/or my initials are not listed below, I understand that my son/daughter will NOT be released to walk home alone at program-end. : 

 

AUTHORIZED ADULTS 

LEARN will include the names of both parents/guardians listed on this Registration Form as Authorized Adults in the student information system. LEARN will only remove a parent from the student information system with a legal document that instructs that action, such as valid court documentation that restricts a birth parent’s access to a child. The parent or legal guardian of a student must authorize any other adults they will permit to take physical custody of their child when picking them up from the program. Such authorization must be provided on this form. All authorized adults will be entered into the student information system as being approved by the parent/legal guardian. Only the parent/legal guardian may request changes to the list of authorized adults in the student information system. Authorized adults must produce valid, unexpired, photo identification to LEARN staff. Adults who are not able to produce valid identification will not be allowed to pick-up a student from the program, regardless of whether the adult’s name appears on this form or in the LEARN student information system as an emergency contact or authorized person. It is the sole responsibility of the parent/legal guardian to ensure that LEARN has the correct information for Emergency Contacts and Authorized Adults.

 

EMERGENCY CONTACT 

Adults other than a parent/guardian must be listed as emergency contacts below.

Emergency Contact #1 – Name:   

Emergency Contact #1 – Home Phone Number:   

Emergency Contact #1 – Mobile Phone Number:   

Emergency Contact #1 – Relation to Student:   

Emergency Contact #2 – Name:   

Emergency Contact #2 – Home Phone Number:   

Emergency Contact #2 – Mobile Phone Number:   

Emergency Contact #2 – Relation to Student:   

 

ADULTS AUTHORIZED TO PICK-UP STUDENT 

Students in Grade TK – 5 will only be released to an authorized adult (over 18 years of age). The Authorized Adults must be listed below.

Authorized Person #1 – Name:   

Authorized Person #1 – Phone Number:   

Authorized Person #1 – Relation to Student:   

Authorized Person #2 – Name:   

Authorized Person #2 – Phone Number:   

Authorized Person #2 – Relation to Student:   

Authorized Person #3 – Name:   

Authorized Person #3 – Phone Number:   

Authorized Person #3 – Relation to Student:   

 

PROGRAM GUDELINES

  • The first day of the program will be the first day of school in August 2017 and will continue until the last day of school in June 2018, as long as there are enough students enrolled to secure the required staff.
  • ASPIRE PLUS students are not held to any strict attendance or early release policy requirements.
  • The Student Code of Conduct enforced during the school day at your child’s school will also be enforced during the after school program and students may be dropped from the program for unacceptable behavior.
  • Students may travel in order to participate in off-site field trips and/or KidsPlay sports leagues and parents/guardians will receive sufficient advance notice and schedules of such off-site activities.
  • One of the parents/guardians is required to attend a Parent Orientation at the beginning of the school year. Failure to attend will result in your child’s dismissal from the program. The Site Coordinator will announce dates early in the school year for your child’s school.

 

CONSENT TO USE OF VIDEO OR PHOTOGRAPHY 

I understand that LEARN personnel may photograph and/or film my child during the program and I hereby consent to use of these photographs/video in LEARN’s promotional material.

 

LIABILITY WAIVER

I hereby waive all claims against my child’s school district, LEARN and its employees for injury, accident or illness occurring by reason of participation in the ASPIRE PLUS program. In case of an emergency, I authorize and licensed physician or hospital to render such medical aid as may be deemed necessary and/or desirable. Any cost/liability incurred for such treatment shall be my sole responsibility.

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Signature Certificate
Document name: ASPIRE Plus Registration Form
Unique Document ID: d8051d4de3179cccbcbd5de2b0f5b40ce3707ece
Timestamp Audit
2017-06-16 14:57:20 PDTASPIRE Plus Registration Form Uploaded by Brenda Carrillo - brenda@learnla.org IP 173.55.35.183
2017-06-20 11:38:22 PDT Document owner dallas@learnla.org has handed over this document to brenda@learnla.org 2017-06-20 11:38:22 - 172.249.205.110