AFTER SCHOOL PROGRAM ENROLLMENT AGREEMENT

PROGRAM INFORMATION

[PROGRAM NAME] ("Program")

Location: [ADDRESS]
Phone: [PHONE]
Email: [EMAIL]
Website: [WEBSITE]
License Number (if applicable): [LICENSE NUMBER]

CHILD AND FAMILY INFORMATION

Child Information

Parent/Guardian 1 (Primary Contact)

Parent/Guardian 2

Custody/Legal Arrangements

☐ Parents share equal custody
☐ Primary custody with: [NAME]
☐ Court order on file: ☐ Yes ☐ No
☐ Restraining order on file: ☐ Yes ☐ No

If there are any custody restrictions, please provide court documentation.

SECTION 1: PROGRAM ENROLLMENT

1.1 Program Schedule

Program Hours: [START TIME] to [END TIME]

Days Enrolled:
☐ Monday ☐ Tuesday ☐ Wednesday ☐ Thursday ☐ Friday

☐ Full-Time (5 days)
☐ Part-Time: [SPECIFY DAYS]
☐ Drop-In (as available)

Program Dates:
- Start Date: [DATE]
- End Date: [DATE]
- Program follows [SCHOOL DISTRICT] calendar for closures

1.2 Program Components

The Program includes:

☐ Transportation from school (if applicable)
☐ Homework help/Quiet study time
☐ Snack
☐ Supervised recreation
☐ Enrichment activities: [SPECIFY]
☐ Arts and crafts
☐ Physical activity/Sports
☐ STEM activities
☐ Reading/Literacy programs
☐ Other: [SPECIFY]

1.3 School Pick-Up (if applicable)

☐ Program provides transportation from: [SCHOOL NAME(S)]
☐ Pick-up location: [LOCATION AT SCHOOL]
☐ Parent is responsible for transportation to Program

SECTION 2: FEES AND PAYMENT

2.1 Tuition/Fees

2.2 Payment Terms

Tuition Due: [WEEKLY/BI-WEEKLY/MONTHLY] on [DAY/DATE]

Payment Methods:
☐ Cash
☐ Check (payable to [PROGRAM NAME])
☐ Credit/Debit Card
☐ ACH/Bank Draft
☐ Online Payment

Auto-Pay: ☐ Required ☐ Optional ☐ Discount of $[AMOUNT] for auto-pay

2.3 Late Payment

☐ Late fee of $[AMOUNT] charged after [DATE/DAY]
☐ Child may be excluded from Program after [NUMBER] days past due
☐ Re-enrollment denied if prior balance unpaid

2.4 Returned Payments

☐ Returned check/ACH fee: $[AMOUNT]
☐ After [2] returned payments, cash or money order required

2.5 Sibling Discount

☐ [PERCENTAGE]% discount for second child
☐ [PERCENTAGE]% discount for third+ children

2.6 Subsidies and Assistance

☐ Program accepts [STATE/LOCAL] childcare subsidies
☐ Financial assistance available: ☐ Yes ☐ No
☐ Scholarship: ☐ Applied ☐ Received ☐ Not applicable

SECTION 3: ATTENDANCE AND SCHEDULE

3.1 Attendance

☐ Notify Program of absences by [TIME] via [METHOD]
☐ No refunds or credits for absences
☐ Pattern of unexplained absences may result in dismissal

3.2 Late Pick-Up

Program ends at [END TIME].

☐ Pick-up must occur by [TIME]
☐ Late fee: $[AMOUNT] per [15] minutes after [TIME]
☐ After [3] late pick-ups, enrollment may be reconsidered
☐ If child not picked up by [TIME], emergency contacts will be called
☐ If no one reachable by [TIME], authorities may be contacted

3.3 Early Pick-Up

☐ Early pick-up available
☐ Notify staff of early pick-up by [TIME]
☐ Sign-out required for all pick-ups

3.4 School Closures and Holidays

When school is closed:
☐ Program operates on school closure days: ☐ Yes ☐ No
☐ Full-day care available on school closure days: $[AMOUNT] additional
☐ Program closed on: [LIST HOLIDAYS]

Inclement Weather:
☐ Program follows [SCHOOL DISTRICT] closures
☐ Check [WEBSITE/APP/PHONE] for closure announcements
☐ No refunds for weather-related closures

3.5 Schedule Changes

☐ [2] weeks notice required to change schedule
☐ Permanent schedule changes subject to availability
☐ Temporary schedule changes: [POLICY]

SECTION 4: DROP-OFF AND PICK-UP

4.1 Authorized Pick-Up Persons

ONLY individuals listed below may pick up your child. Photo ID required.

4.2 Pick-Up Procedure

☐ Photo ID required for all pick-ups
☐ Child will not be released to anyone not on authorized list
☐ Parent must notify Program in writing to add or remove authorized persons
☐ Child will not be released to anyone appearing impaired

4.3 Student Sign-Out

☐ Children may sign themselves out: ☐ Yes (Grade [5]+) ☐ No
☐ Walking permission (if applicable): ☐ Granted ☐ Not granted
☐ Written permission on file for self-dismissal

SECTION 5: HEALTH AND SAFETY

5.1 Health Forms

Required before first day:
☐ Completed enrollment forms
☐ Emergency information
☐ Immunization records
☐ Health history and allergies
☐ Medication authorization (if applicable)
☐ Physical examination (within past [12] months): ☐ Required ☐ Not required

5.2 Immunizations

☐ Program requires all state-mandated immunizations
☐ Exemptions accepted: ☐ Medical ☐ Religious ☐ None

5.3 Allergies and Medical Conditions

Allergies: _________________________________

Medical Conditions: _________________________________

Medications (regular use): _________________________________

Dietary Restrictions: _________________________________

Physical Limitations: _________________________________

5.4 Medication Administration

☐ Program ☐ will ☐ will not administer medications
☐ Prescription medications require written authorization
☐ Medications must be in original containers with pharmacy labels
☐ EpiPen/Inhaler authorization: [FORM REQUIRED]

5.5 Illness Policy

Child should not attend if they have:
☐ Fever of [100.4]°F or higher
☐ Vomiting or diarrhea (within past [24] hours)
☐ Undiagnosed rash
☐ Contagious illness
☐ Symptoms requiring exclusion per [STATE/HEALTH DEPT] guidelines

Return to Program: Child must be symptom-free for [24] hours without medication.

5.6 Injury and Illness at Program

☐ Minor injuries treated with basic first aid
☐ Parents notified of injuries/illness
☐ For serious injuries: 911 called, then parents notified
☐ Incident report completed for all injuries

5.7 Medical Emergency Authorization

☐ In case of emergency, I authorize Program staff to seek emergency medical treatment
☐ I consent to treatment deemed necessary by medical personnel
☐ I agree to be responsible for all medical costs

Parent/Guardian Initials: _______ Date: _______

SECTION 6: BEHAVIOR AND DISCIPLINE

6.1 Expectations

Children are expected to:
☐ Follow staff instructions
☐ Treat others with respect
☐ Use appropriate language
☐ Keep hands and feet to themselves
☐ Care for Program property and materials
☐ Participate in activities

6.2 Discipline Policy

Positive Guidance: Program uses positive reinforcement and redirection.

Progressive Discipline:
1. Verbal warning and redirection
2. Time-out/Cool-down period
3. Parent notification
4. Parent conference and behavior plan
5. Suspension
6. Dismissal from Program

6.3 Prohibited Behaviors

The following may result in immediate dismissal:
☐ Violence or aggression toward others
☐ Bullying or harassment
☐ Possession of weapons
☐ Destruction of property
☐ Leaving Program area without permission
☐ Behavior endangering self or others

6.4 Suspension and Dismissal

☐ Program reserves right to suspend or dismiss for behavioral issues
☐ No refund of fees for dismissal due to behavior
☐ Dismissal decision is final

SECTION 7: EMERGENCY CONTACTS

7.1 Emergency Contacts

7.2 Medical Information

Primary Care Physician: _________________ Phone: _____________

Hospital Preference: _________________________________

Insurance Carrier: _________________ Policy #: _____________

SECTION 8: LIABILITY AND RELEASE

8.1 Assumption of Risk

I understand and acknowledge that:
☐ After school activities involve inherent risks
☐ My child may participate in physical activities, arts, and recreational activities
☐ Minor injuries may occur despite reasonable precautions
☐ I voluntarily enroll my child with knowledge of these risks

8.2 Release of Liability

I hereby RELEASE, WAIVE, AND HOLD HARMLESS [PROGRAM NAME], its owners, directors, officers, employees, and agents from any claims, demands, or causes of action arising from my child's participation in the Program, except for gross negligence or willful misconduct.

8.3 Indemnification

I agree to INDEMNIFY AND HOLD HARMLESS the Program from claims arising from:
☐ My child's conduct
☐ Inaccurate information provided by me
☐ My failure to provide required medical information

8.4 Personal Belongings

☐ Program is not responsible for lost, stolen, or damaged personal belongings
☐ Label all belongings with child's name
☐ Do not send valuable items or electronics

SECTION 9: PHOTO/VIDEO RELEASE

☐ I GRANT permission for Program to photograph/video my child for:
☐ Program website
☐ Social media
☐ Newsletters and promotional materials
☐ Internal documentation

☐ I DO NOT GRANT permission

SECTION 10: FIELD TRIPS (IF APPLICABLE)

☐ Program conducts field trips: ☐ Yes ☐ No

☐ I grant blanket permission for my child to participate in Program field trips
☐ I prefer to sign individual permission slips for each field trip

☐ I grant permission for Program-arranged transportation on field trips

SECTION 11: WITHDRAWAL AND TERMINATION

11.1 Withdrawal by Parent

☐ [2] weeks written notice required to withdraw
☐ Tuition due through notice period
☐ No refunds for partial weeks/months

11.2 Termination by Program

Program may terminate enrollment for:
☐ Non-payment after [NUMBER] days
☐ Repeated behavioral issues
☐ Failure to comply with Program policies
☐ Parent failure to cooperate with staff
☐ Falsified enrollment information

11.3 Refund Policy

☐ Registration fees are non-refundable
☐ Tuition is non-refundable for enrolled days
☐ Prepaid tuition may be refunded for future weeks with proper notice

SECTION 12: COMMUNICATION

12.1 Communication Methods

☐ Email: [EMAIL]
☐ App: [APP NAME]
☐ Phone: [PHONE]
☐ Newsletter: [FREQUENCY]

12.2 Parent Updates

☐ Daily updates available: ☐ Yes ☐ Upon request
☐ Parent portal access: [URL]
☐ Parent-staff conferences: Available upon request

SECTION 13: BACKGROUND CHECKS AND STAFF

13.1 Staff Qualifications

☐ All staff complete background checks before hire
☐ Staff trained in CPR/First Aid
☐ Staff-to-child ratio: [1:NUMBER]
☐ Ongoing training provided

13.2 Background Check Acknowledgment

☐ I acknowledge that Program has represented it conducts background checks on staff

SECTION 14: GENERAL PROVISIONS

14.1 Handbook

☐ I have received and agree to the Parent Handbook policies
☐ Handbook available at: [LOCATION/URL]

14.2 Amendments

☐ Program may update policies with notice to parents
☐ Fee changes require [30] days notice

14.3 Governing Law

This Agreement is governed by the laws of [STATE].

SECTION 15: PARENT/GUARDIAN ACKNOWLEDGMENTS

By signing below, I acknowledge and agree:

☐ I have read and understand this Enrollment Agreement
☐ I agree to abide by all Program policies
☐ I authorize emergency medical treatment for my child
☐ I agree to the fee schedule and payment terms
☐ I accept the liability release terms
☐ I have provided accurate information about my child
☐ I will keep Program informed of changes to contact/medical information
☐ I understand the attendance and pick-up policies
☐ I understand the behavioral expectations and discipline policy

SIGNATURES

PARENT/GUARDIAN 1:

Signature: _________________________________ Date: _____________

Printed Name: _________________________________

PARENT/GUARDIAN 2 (if applicable):

Signature: _________________________________ Date: _____________

Printed Name: _________________________________

FOR PROGRAM USE ONLY

This After School Program Enrollment Agreement template is provided for informational purposes only and does not constitute legal advice. Consult with a qualified attorney in your jurisdiction before use. Childcare programs may be subject to state licensing requirements.