After School Program Enrollment Form

After School Program Enrollment Form

2022-2023
Cannon School is pleased to offer our After School Program for those families that need care for their children beyond the normal school day. Contract rates offer substantial savings compared to the hourly rates, when used for the full number of hours. Early Dismissal Days are also included in the contract rate. Non-contract students will be charged at a rate of $9.00 per hour on these days.

Please complete and submit one form per student being enrolled in the After School Program.
Parent's Name *

First Name Last Name
Parent's Phone Number *

Area Code Phone Number
Parent's Email *
Student's Name *

First Name Last Name
Grade in fall (2022-2023) *

JrK Kindergarten Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 Grade 7 Grade 8
Effective date for enrollment in After School Program *

Month Day Year
Please indicate the month and day that this agreement is to take effect. For example, if you will be using the After School Program from the first day of school, enter 08-18-2022.
Please check the After School Program enrollment option desired for your child: *

1 day per week (annual contract rate of $920) 2 days per week (annual contract rate of $1,720) 3 days per week (annual contract rate of $2,400) 4 days per week (annual contract rate of $2,970) 5 days per week (annual contract rate of $3,416) Drop-in rate of $9.00 per hour
Indicate the day(s) that you anticipate utilizing the After School Program: *

Monday Tuesday Wednesday Thursday Friday
Please indicate your child's default dismissal plan:
My child will remain in the After School Program until being picked up on:

Monday Tuesday Wednesday Thursday Friday
My child will take the Cannon School Activity Bus (available only for Middle School Students) on:

Monday Tuesday Wednesday Thursday Friday
Please note any known allergies:
Please specify each person, including the name of parents, who has permission to pick up your child from the After School Program.
Authorized Person 1:

First Name Last Name
Phone Number 1:

Area Code Phone Number
Authorized Person 2:

First Name Last Name
Phone Number 2:

Area Code Phone Number
Authorized Person 3:

First Name Last Name
Phone Number 3:

Area Code Phone Number
Authorized Person 4:

First Name Last Name
Phone Number 4:

Area Code Phone Number
Statement of Fees
Statement of Policy
- An Enrollment Form is required for all students participating in this program.
- Contracts will be billed 50% of rate in September and 50% of rate in January. Drop-in charges and late fees will be billed monthly. Payments are due upon receipt. A late fee will be assessed at a rate of 1.5% per month on all accounts past due. Delinquent accounts may result in dismissal of student from the After School Program. Please note that contract changes can only be made in August & January of each year .
- The After School Program ends promptly at 6:00 p.m. After 6:00 p.m., a late charge will be assessed at the rate of $10.00 for each 10 minute interval or fraction thereof.
- If a student’s use of the program exceeds the number of days of his/her contract, the hourly rate will apply for the additional hours.
- JrK-8th grade students remaining on campus after 3:00 p.m. are required to attend our After School Program unless they are participating in a supervised program such as sports, tutoring, clubs, or a Beyond the Bell enrichment offering.
- Students may participate on a drop-in basis with prior notification from parents. If no Enrollment Form has been previously submitted, you will be sent an email with the link to this form to complete and submit.
- Only persons authorized by the parent or guardian may pick up your child from the After School program. Please notify the Enrichment Programs office in writing if anyone other than a parent/guardian will pick up your child.
- All students attending the After School Program are required to follow all school and program rules. Behavioral problems will result in parent notification and possible suspension from the program.
- Students with a fever or contagious illness may not participate in the program.
- This program is available for all currently enrolled Cannon students, grades JrK - 8.
- Fall semester After School Program runs from August 18, 2022 – December 16, 2022.
- Spring semester After School Program runs from January 3, 2023 – June 1, 2023.
I have read and understand the Statement of Fees and Statement of Policy contained here. *

Agree
I give Cannon School permission to bill my student's account for the After School Program services indicated on this Enrollment Form, according to the Statement of Fees. *

Agree
Should be Empty:

After School Program Enrollment Form

Statement of Fees

Statement of Policy