SPA After-school Enrollment

Afterschool STEM

Stem Prep Academy
- School Year: September-June
- Pick up from Adaire
- Snacks Provided
- Registration fee $207.41
- Tuition is $1100 monthly
E-mail:*
How did you hear about us?
Child's Full Name:*

Prefix First Name Last Name
Child's Nick Name:
Child's Date of Birth:*
MM/DD/YYYY
Child's Grade:*
MM/DD/YYYY
For reporting purposes, please indicate your child's ethnicity (optional):

African AmericanLatino/HispanicCaucasianNative AmericanAsian American
School Year:*

2022-2023
Enrollment Options*

Monday- Friday (after school until 5:30 pm)
What time does your child get out of school?*
Where is the pickup location at the school?*
Provide teacher's full name, room number and email if known (must be provided at least by first week of after school program):
All known food and/or drug allergies:*
Any medical conditions or learning or physical disabilities of which we should be aware of:*
Child's T-shirt Size (Youth):*

5T6T
Are there any recent traumatic situations your child has been exposed to such as a death in the family, divorce, new sibling, etc.?*
What is your normal method of discipline?*
What is your child's temperament? Are they easy going, quiet, hard to please, demanding, aggressive, etc.?*
Child's Health Records (a copy of your students immunizations and current health report are required-attached). You may upload now or bring in on their first day of attendance:

Browse Files

Cancelof
Download & Print Child Health Report.
Are there any medications your child will be taking while in school? *
Please include any medical papers necessary in case of an emergency. Non-prescription medication and prescription must be signed in during attendance.
Are there any other comments or information you would like us to know?
Physicians Name:*
Phone Number*

Area Code Phone Number
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Insurance Name:*
ID:*
Group:
Parents Full Name*

First Name Last Name
Annual Household Income (optional):

0-$19,999$20-39,999$40-49,999$50-59,999$60-89,999$90-119,999$120+
Highest Level of Education (optional):

Up to 8th gradeSome High SchoolHigh School GraduateSome CollegeCollege GraduateMastersPhD/MD/JD
Address:*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number:*

Area Code Phone Number
Parents Full Name

First Name Last Name
Email
example@example.com
Annual Household Income (optional):

0-$19,999$20-39,999$40-49,999$50-59,999$60-89,999$90-119,999$120+
Highest Level of Education (optional):

Up to 8th gradeSome High SchoolHigh School GraduateSome CollegeCollege GraduateMastersPhD/MD/JD
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number:

Area Code Phone Number
Emergency Contact Name:*
Emergency Contact Number:*
Emergency Contact Name:
Emergency Contact Number:
Authorized to Pick up/Drop off
Name:*
Relationship to Student:*
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone: *
Name:*
Relationship to Student:*
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone:*
I understand that as a part of Stem Prep Academy, my child may be videotaped, audiotaped, interviewed, and/or photographed and agree to allow Stem Prep Academy to keep, as Stem Prep Academy property, the products of such videotaping, audiotaping, interviewing, and/or photographing. I agree that such material, along with my child’s name, may be used, and posted on the Stem Prep Academy's website, Instagram, and Facebook, for promoting and in any publicity generated by Stem Prep Academy. I also understand that my child may be asked to do or participate in projects that may also be used by Stem Prep Academy for publication in a variety of forums newsletters, websites, and other publications, and that no compensation will be paid for such use.

I understand that participating in Stem Prep Academy allows my child no special rights or expectations regarding Stem Prep Academy, including the right to sue any party involved in the implementation and execution of the Stem Prep Academy's programs. I agree to hold harmless Stem Prep Academy, its agents, and employees from all claims, damages, losses, injuries, and expenses arising out of or resulting from participation in these activities. I further agree not to sue Stem Prep Academy, their agents, and employees for any actions or causes of action, including the negligence of Stem Prep Academy arising out of participation in this program.
I agree
I disagree
Registration: The registration fee is non-refundable and is $207.41

Enrollment: Enrollment runs September through June, a 30 day notice is required when leaving program.

Tuition: Afterschool tuition is due monthly on the 1st via our payment platform bright wheel.

Refund: Tuition, registration and all fees are non-refundable. Days missed can not be credited. Slots are monthly and are not pro-rated.

If a child or staff member has a confirmed diagnosis of COVID-19:

All children and staff who have come in close contact with (defined as greater than 10 minutes of interaction less than 6 feet away) must quarantine at home for 10 days (tuition during this time period will not be refunded however work will be sent home with the child).

Partial refunds will not be made if days are missed, or your child is unable to attend. Stem Prep Academy will apply a reversal fee in the amount of $50.00 for payments that are returned. A late fee in the amount of $5 per minute will be administered if your child is not picked up within 5 minutes of their scheduled time. This must be paid before your child returns to school. Tuition is not prorated, families pay for slots in which tuition is a set amount monthly.

We offer sibling and teacher discounts of 5% for families. Do you know a family that would benefit from enrolling at SPA? You will receive $100 instantly and an additional $100 after 3 months of enrollment. Do you know a business that would like to provide affordable pre-k and kinder education to its employees? Ask us about our business partnership program at no cost.

OBTAINING EMERGENCY MEDICAL CARE AND ADMIN. OF MINOR FIRST AID PROCEDURES: THE PARENT'S SIGNATURE IS REQUIRED FOR EACH ITEM BELOW TO INDICATE PARENTAL CONSENT!

1. WALKS AND TRIPS

2. TRANSPORTATION BY THE FACILITY

3. WADING

SPA AFTER SCHOOL*

After school Registration Fee (September-June)$207.41

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Total $0.00

Credit Card

Tuition (for administrative use only)
Signature*

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Name*

First Name Last Name
Drivers License Number*
Todays Date*
Directors Signature:

Clear
Should be Empty:

Afterschool STEM

Authorized to Pick up/Drop off

Credit Card