2022-2023 After School Enrollment Form

The Sal After School Program Enrollment 2022-2023

1707 W. Chestnut Expressway Springfield, MO 65802 (417)862-5509 x 113
Dates: August 22, 2022-May 24, 2023

Hours: Monday- Friday 2:30pm-6:30pm
The Sal will be open Monday-Friday from 2:30pm-6:30pm. Fees: $45 per child per week for all schools attending after school ONLY (will receive dinner each night at 4:30pm)

$20 per child per full day rate for single days out of school (Snow Days, holidays, teacher work days) -these days will include breakfast, lunch, & afternoon snack.

***By registering you are signing up your child to attend The Sal After School Program for the entire school year. If you wish to remove your child from The Sal prior to the end of school, a written two week notice must be given and fees must be paid in full.***
Dates The Sal will be CLOSED:

Monday, September 5, 2022: Labor Day

Thursday & Friday, November 24 & 25, 2022: Thanksgiving

Thursday & Friday, December 23 & 26, 2022: Christmas

Thursday & Friday, December 30, 2022 & January 2, 2023: New Year's

Monday, January 16, 2023: MLK Day

Monday, February 20, 2023: President's Day

Friday, April 21, 2023: Good Friday

Thursday & Friday, May 25 & 26, 2023: Day Camp prep days (will be last two full days of school depending on snow days)
Child's Details

Please complete one form for each child
Child's Name*

First NameLast Name
Child's Birth Date

MonthDayYear
Child's Gender*
What school does your child attend?*
Please note: We only pick up for after school program at the current schools: York, Bissett, Westport, Williams, Willard South, Willard Orchard Hills, & St. Joseph's. If you register and we do not pick up from your school we will assume you are enrolling for all day out ONLY.
Does your child attend Springfield Public Schools?*

YesNo
What is your child's SPS Student ID #?*
What grade will your child be in during the 2022-2023 school year? (We only accept kids grades K-7th).*

Kindergarten1st2nd3rd4th5th6th7th
What type of care are you needing? (Select all that apply)

After School Care (Daily pick up from your child's school)All Day Out of School Care (Christmas Break, Spring Break, Snow Days, etc.)
Child Reside With?*
Parent Info
Primary Parent Name*

First NameLast Name
Primary Parent Phone Number*

Area CodePhone Number
Primary Parent Email Address*
We will use this email to communicate throughout the summer and send billing invoices to on a weekly basis.
Child's Address (Primary Parent)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Parent Occupation/Place of Employment*
Primary Parent Work Schedule*
Primary Parent Work Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Parent Work Phone Number*

Area CodePhone Number
Secondary Parent Name

First NameLast Name
Secondary Parent Phone Number

Area CodePhone Number
Secondary Parent Email Address
example@example.com
Secondary Parent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Parent Occupation
Secondary Parent Work Schedule
Secondary Parent Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Parent Work Phone Number

Area CodePhone Number
Enrollment Details

Weekly fees are due every Friday. Failure to make the weekly payment on Fridays will cause removal from enrollment. Payments can be made at The Salvation Army main office at 1707 W. Chestnut Expressway. We accept cash, check, or money order.
Will you be applying for state child care assistance? (Paperwork must received by The Sal to begin charging subsidy rate). The Sal provider number is: 000497501.*

YesNo
Emergency Contacts & Authorized Pick Ups

We only allow authorized family members & friends to pick up registered children. Please provide contact information for two non-parent emergency contacts in the case that parent/guardian cannot be reached in an emergency. Please list first & last name of anyone authorized to pick your child up who has not already been listed.
Emergency Contact #1 Name (Not a parent or guardian)*

First NameLast Name
Emergency Contact #1 Phone Number*

Area CodePhone Number
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this emergency contact authorized to pick up the child?*

YesNo
Emergency Contact #2 Name (Not a parent or guardian)*

First NameLast Name
Emergency Contact #2 Phone Number*

Area CodePhone Number
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this emergency contact authorized to pick up the child?*

YesNo
First & Last Name of anyone authorized to pick up your child from The Sal
Phone Number

Area CodePhone Number
First & Last Name of anyone authorized to pick up your child from The Sal
Phone Number

Area CodePhone Number
First & Last Name of anyone authorized to pick up your child from The Sal
Phone Number

Area CodePhone Number
First & Last Name of anyone authorized to pick up your child from The Sal
Phone Number

Area CodePhone Number
Health Information
Select One:*

My child is in good health, is able to participate in group care, has no special health or medical requirements.My child is able to participate in group care but has special health or medical requirements as listed below.
Please list any allergies, special medical conditions, including chronic health problems (such as asthma, seizures), behavior disorders, special needs, etc. (if none write none or n/a)*
Child's Health Details
Medical Practioner Name*
Medical Practioner Phone Number*
Preferred Hospital Name*
Preferred Hospital Phone Number*
Does your child have an immunization record?*

YesNo
Attach a copy of your child's immunization record or bring a copy into our main office at 1707 W. Chestnut Expressway. (Registration is not considered complete until we receive the child's immunization record.)
Will The Sal be dispensing medication to your child during After School (including all day outs)?*

YesNo
If yes, please explain and provide a medical care plan to The Sal before start of after school
Does your child have allergies or sensitivities?*

YesNo
If yes, please explain and provide a medical plan to The Sal before start of after school
Does your child have any other diagnosed behavioral or medical conditions?*

YesNo
If yes, please explain and provide a medical plan or a copy of the child's IEP to The Sal before start of after school
Does your child have any dietary restrictions?*

YesNo
If yes, please explain and provide a food substitute plan to The Sal before start of after school
Health Permission Form

A The Sal may also administer suncsreen or bug spray (when provided by parents), hand sanitizer, unscented lotion, and Vaseline for chapped lips. I have read & checked all that apply to my child and signed below all applicable information regarding to the care of my child:
Staff may give my child sunscreen (parent must provide)*

YesNo
My child has had an allergic reaction to sunscreen.*

YesNo
If yes, what brand?
Staff may give my child hand sanitizer. (The Sal will provide)*

YesNo
Staff may give my child unscented lotion for dry skin. (The Sal will provide)*

YesNo
Staff may give my child Vaseline for chapped lips. (The Sal will provide)*

YesNo
About Your Child

The most important element in our partnership with you is honest and complete personal information about your child. In order to meet each child's needs, we need as much relevant information as possible. Such information can be invaluable in helping your child make a smooth and happy transition from school to after school. Having prior knowledge about a child’s background, an emotional upset, or a recent problem can be the crucial factor in helping us be sensitive to your child's needs. Since children often use their behavior rather than words to tell us what's bothering them, our having advance knowledge of sensitive issues helps us understand the message in a child’s actions. This information will only be used by ourselves and your child’s team of staff and only with the utmost discretion. And should you wish that we share this information on a “need to know” basis only, we will respect your request. Lastly, we’ll certainly let you know if your child is having difficulty related to this information.
List any activities, hobbies, or interests that your child devotes time to.*
Is your child ever teased? About what? How does he/she react?*
Have there been any changes in your child's home life during the past 12 months (including, but not limited to, the arrival of a new sibling, parents separation or divorce, new step-parent and/or blended family, death of family member, etc.)? If yes, please explain.*
Is there anything else we should know about your child?*
Parent Consent
I do give consent for my child to participate in any and all field trips given by The Sal. It is my understanding that I will be notified in advance of all such trips.*

YesNo
Do you consent to The Salvation Army to seek medical treatment for your child from a medical practitioner, hospital or ambulance in the event you can not be contacted?*

YesNo
Do you consent for The Sal to take photographs and videos of your child during normal activities and excursions?*

YesNo
Declarations
*

I agree to read The Sal Day Camp policies and procedures handbook (link available on The Salvation Army's website and will be emailed a copy upon enrollment) and agree to follow these as a condition of enrollment.
*

I understand The Salvation Army Summer Day Camp hours are 7:30am-6:30pm and if I arrive after 6:30pm to collect my child, The Salvation Army may charge me a Late Collection Fee of $1 per minute late which I agree to pay within one week.
*

I agree to give two weeks written notice of my child leaving The Sal Day After School Program or equivalent fees may be charged
*

I hereby release The Salvation Army and its personnel of any responsibility for personal injury sustained by my child while in attendance at The Sal.
*

I understand that The Sal personnel reserve the right to terminate my child’s membership at any time it is determined that participation is unsatisfactory and that no refunds will be given.
*

I understand that I am responsible for paying any damage and/or replacement costs incurred by my child to Salvation Army property and/or equipment.
*

I agree to keep my child's information up to date, including but not limited to, phone numbers, address, email address, immunization, health information and family information.
*

I agree to collect or make arrangement for the collection of my child if they become unwell during after school.
*

I agree to keep my child away from after school if they display any symptom which would be considered contagious.
*

I am aware that fees are charged weekly and non-payment will result in cancellation of my child's enrollment.
*

I understand that The Sal Community Center and all programs and activities offered are sponsored by The Salvation Army and that Christian attitudes and values will be stressed.
*

I agree that I have been informed of the required health and safety inspections (form below) and that the inspection forms are available to review.
*

I declare the information provided in this form is true and correct
*

I declare that I am the applicant named in the form, and that all information and documents provided as part of my application are true and correct.
State Required Notice of Parental Responsibility
Signature

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The Sal After School Program Enrollment 2022-2023

Dates: August 22, 2022-May 24, 2023

Child's Details

Parent Info

Enrollment Details

Emergency Contacts & Authorized Pick Ups

Health Information

Child's Health Details

Health Permission Form

About Your Child

Parent Consent

Declarations