Springfield Academy/Spring "N" Dale Private School

                                                Child Care Center Registration Form

Please Use Black Ink

Child's Name:

Nick Name:

Date of Birth:

                       Last                             First                         Middle

Street Address:

Home Phone:

City:

State:

Zip Code:

Father's Name:

Cell Phone:

Employer:

Business Phone:

Mother's Name:

Cell Phone:

Employer:

Business Phone:

Legal Status of Child's Custody:

Physician's Name:

Telephone:

Hospital Preferred (in case of emergency):

Name of a relative, friend or otherwise responsible person to contact in case parents cannot be reached:

1. Name:

2. Name:

    Address:

    Address:

    Relationship:

    Relationship:

    Telephone:

    Telephone:

Who is authorized to pick up this child?

Who is NOT authorized to pick up this child?

Desired entrance date:

Re-entry date:

Who referred you to this school?

Center/School previously attended:

How long?

Please list any food or drug allergies:

 

 OFFICE USE ONLY

Registration Fee:

Grade or Class:

First Weeks Tuition:

Family Registration Fee:

Date Admitted:

Drop off Hour:              Pick up Hour:

Date of Withdrawal:

Tuition Rate Weekly/Monthly:

Reasons for Withdrawal:

Administrator of Child Care Center

                                    Date:

 Merit Education Inc.

Excellence in Education with a Homelike Atmosphere

Registration Agreement

IMPORTANT:  Many of our classes fill up very quickly and we often have waiting lists.  Prior to sending in Registration Agreement, please call (703) 256-3773 to confirm availability and to reserve your child's place in our program.  Placement in our program is only allocated with verbal confirmation.

I.  The child/children listed below is/are enrolled in either Spring "N" Dale and/or Springfield Academy and the following establishes the guidelines for much of the conduct of the child/children in the School(s).

II.  PERMISSION.  I grant to Spring "N" Dale and/or Springfield Academy  permission for my child/children to take part in all School activities, including bus trips, sports activities, and School sponsored trips away from the School's premises.

Spring "N" Dale and/or Springfield Academy is/are authorized to obtain immediate medical care for my child/children if an emergency occurs and I cannot be located immediately.  I understand that the School will notify me immediately whenever my child becomes ill and I will pick up the child from School as soon thereafter as practicable.

I give permission for my child's teacher or another School official to make and enforce classroom regulations in a manner consistent with the School's policy and good discipline.  I understand the school reserves the right to dismiss my child/children at any time if my child/children become unmanageable or disrupt the promulgation of the academic program(s) in the classroom.

III.  PAYMENT.  I agree to pay the established tuition on either a monthly/bi-weekly or weekly basis, in advance, payable on the first (1st) day of the payment schedule which I choose.  I understand that there will be no deductions from the tuition for absences of my child/children.  If I decide to withdraw my child/children, I agree to give two (2) weeks written notice before such withdrawing, provided in lieu of this two (2) weeks notice, two (2) weeks tuition will be paid at the established tuition rate.

A service charge of Twenty-Five Dollars ($25.00) will be paid by me if my monthly tuition is not paid on or before the fifth day of the due month.  If I pay other than monthly, I agree to pay the established service charge set forth in School policies if my tuition payment is not made on the first (1st) day of the payment schedule which I choose.  This payment will be due regardless of the cause for delay.

In the event a check of mine is returned by my bank for any reason, I agree to pay a processing charge to the School of Thirty Dollars ($30.00) for such returned check and to immediately replace the check with cash or its equivalent.  The enrollment fee which I have paid, I understand to be non-refundable.

IV.  INDEMNIFICATION.  I agree to indemnify and hold the School and all of its employees and agents harmless for any liability whatsoever, to my child or any guardian or any parent thereof because of any injury or alleged injury to my child.  In the event legal action is instituted against the School or any employee or agent thereof and the person instituting such action is not the prevailing party, I agree immediately upon demand to reimburse the School, its agents, and employees for all attorney's fees, costs and other expenses incurred by the School and its agents in defending any action against them.  I also agree to pay reasonable attorney's fees and other costs and expenses incurred by the School in collecting or attempting to collect any obligations which I owe to the school.

By signing below, I hereby acknowledge that I have read, understood and agree to all the policies set forth in the school information packet, also acknowledging receipt of same.    

This Agreement shall be in effect for as long as my child/children is/are enrolled at either of the Schools.

List Child/Children's Name(s):   

Parent(s)' Signature(s): (both must sign)