Explorer Club Registration Form

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Explorer Club - Before/After Care Program
13954 W.Waddell Rd P.O. Box 223
Surprise,Az 85379 P.480-285-5992

Site Location:
Discover U
13226 N 113th Ave
Yougtown AZ 85363

Child's Last Name: *

Child's First Name: *

Birth Date: *

Address: *

City & Zip: *

Gender: *

Male

Female

Grade Entering Year 2016 *

Child resides with? *

Both parents

Mother

Father

Other:

Are there any custody agreements in force? (If yes, you must submit a copy of the agreement) *

Yes

Does this student currently have an IEP (Individual Education Plan)? *

Yes

Does this student currently have a 504 Accommodation Plan? *

Yes

Does this student have any physical or mental impairment? *

Yes

Does the student have any allergies? *

Yes

If yes to allergies, please explain:

Mother/Guardian Name: *

Cell Phone: *

Work Phone:

Home Phone:

Address: *

City & Zip *

Father/Guardian Name: *

Cell Phone: *

Work Phone:

Home Phone:

Address: *

City & Zip: *

Primary Email Address: *

Emergency Contact Name *

Emergency Contact Phone # *

Additional person authorized to pick up

Additional person phone #

Choose the Before & After Care plan your child will attend for the 2016-2017 school year: *

Fees are based on annual enrollment and are payable in ten (10) equal monthly installments. Rates are based on 180 school days. A per family non-refundable registration fee of $20 and the first month's payment are due immediately. Monthly payments are due the first of each month through May. No registration fee is required for Sibling Care.

Mornings and Afternoons - $190.00 per month

Mornings Only - $80.00 per month

Early Release Days Only $70.00 per month

Drop In - $20.00 a day

Sibling Care - $25.00 per month Times are 2:30pm to 3:00pm Monday through Thursday; 11:45am - 12:15pm Friday's

Parent/Guardian Agreement *

Click the following link to view the Explorer Club Handbook: https://goo.gl/mzehNB

I have read the Explorer Club Handbook and agree to follow all rules, policies, and procedures. Clicking the box serves as your electronic signature.

Required

Explorer Club Financial Agreement *

Click the following link to view the Explorer Club Financial Agreement: https://goo.gl/pD2nuC

I have read the Explorer Club financial agreement and agree to all the terms. Clicking the box serves as your electronic signature.

Required

Guidance and Discipline *

I understand that while my child participates in the Explorer Club, it is my child's responsibility to follow all direction given by the Explorer Club members. The team members will do everything possible to rectify any issues that may arise. However, in the unlikely event there is a disciplinary problem that cannot be resolved, I will be notified and expected to pick up my child as soon as possible. At this time, I fully understand that the outcome could result in my child not being able to return to the program until further notice. In order to stay in compliance with the Student and Parent Handbook Discipline Procedures set forth by Discover U, this resource will be used to determine consequences. This may result in my child's suspension/expulsion. In the case of a suspension/expulsion of my child, I understand that the necessary consequences would be effective immediately and would require immediate action on my part as the parent/guardian, I have discussed this policy with my child and he/she understands it fully.

Required

Permission for Use of Photographs *

I hereby grant permission for my child's photograph to be taken at the Explorer Club while participating in daily activities. These photos may be used by Discover U for publicity purposes including brochures, social media and the website.

I grant permission for my child to be photographed.

I do not grant permission for my child to be photographed.

Medical Authorization *

I hereby consent to my child receiving medical treatment which is deemed advisable in the event of any injury, accident or illness during my child's participation in the program.

I consent to my child receiving medical treatment.

I do not consent to my child receiving medical treatment.

Name of person completing this registration: *

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