Esteem Girls After-school Enrollment

Afterschool STEAM Enrichment

Esteem Girls Inc.
- Tuesday, September 6, 2022-Tuesday June 13, 2023
- Girls in grades 1 through 8
- Snacks Provided
- Early Dismissal Days
- Tuition is $300 monthly
- Early Dismissal Days (additional $10/hour)
E-mail:*
How did you hear about us?
Students Full Name:*

PrefixFirst NameLast Name
Students Full Name:

PrefixFirst NameLast Name
Student's Date of Birth:*
MM/DD/YYYY
Student's Date of Birth:
MM/DD/YYYY
School District:*
School District:
School:*
Please Provide Full Name
School:
Please Provide Full Name
Current Grade:*
Current Grade:
For reporting purposes, please indicate your students ethnicity (optional):

African AmericanLatino/HispanicAsian AmericanNative AmericanCaucasianOther
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 and email if known (must be provided by end of first week):
All known food and/or drug allergies:*
Any medical conditions or learning disabilities of which we should be aware of:*
Students T-shirt Size (Women's):*

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Students T-shirt Size (Women's):

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Any medications she will be taking while in our program: *
Please include any medical papers necessary in case of an emergency. Non-prescription medication and prescription must be signed in during attendance.
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:

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Physicians Name:*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

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

First NameLast 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

CityState / Province

Postal / Zip CodeCountry
Phone Number:*

Area CodePhone Number
Emergency Contact Name:*
Emergency Contact Number:*
Emergency Contact Name: *
Emergency Contact Number:*
Authorized to Pick up/Drop off
Name:*
Relationship to Student:*
Home Phone: *
Name:
Relationship to Student:
Home Phone:
Please upload students most recent report card:

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Behavior Agreement
Esteem Girls is very excited about the opportunity to provide academic enrichment for your child! To ensure that each and every student has a great week, we want all of our students and parents to understand and be familiar with the expectations for participants in Esteem Girls programming. Please read with your student and confirm with their signature below.

Student Expectations:

I will cooperate with staff and fellow students in all activities, experiments, & field trips.

I will be responsible for my actions and behavior so that it doesn’t interfere with somebody else’s opportunity to enjoy the program.

I will follow all rules established by myself and fellow students on the Do’s & Don’t list.

I will act and speak positively and kindly to all students and staff (i.e. no swearing, inappropriate remarks, etc.)

I will listen and not talk when others are talking because I want them to do the same for me.

I will have FUN make FRIENDS, AND LEARN new things during the program!
Students who choose not to follow the behavior expectations will be given “three strikes” and then dismissed from the program.
Students Full Name (student type in name)*

First NameLast Name
My student, has my permission to participate in Esteem Girls programming,*
Full Name Here
I understand that as a part of Esteem Girls, my student may be videotaped, audiotaped, interviewed, and/or photographed and agree to allow Esteem Girls to keep, as Esteem Girls property, the products of such videotaping, audiotaping, interviewing, and/or photographing and I agree that such material, along with my child’s name, may be used, and posted on the Esteem Girls website, for promoting the Esteem Girls program and in any publicity generated by Esteem Girls. I also understand that my child may be asked to do or participate in projects that may also be used by Esteem Girls 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 by participating in Esteem Girls, my child becomes part of a program/study concerning girls and their attitudes toward math and science. I also agree to submit my child’s report cards once received on an annual basis as long as they’re participants of Esteem Girls program. I hereby grant permission for my student to participate in this program/study. I further understand that Esteem Girls will only release the information in accordance with Esteem Girls policies and procedures.

I understand that participating in Esteem Girls allows my child no special rights or expectations regarding Esteem Girls, including the right to sue any party involved in the implementation and execution of the Esteem Girls programs. I agree to hold harmless Esteem Girls, their 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 Esteem Girls, their agents, and employees for any actions or causes of action, including the negligence of Esteem Girls arising out of participation in this program.

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

Refund: Tuition, deposits, and all fees are non-refundable and can be applied to other programs Esteem Girls Inc. offer including but not limited to clubs/classes, summer camp, after-school program, STEM Saturday, and tutoring. Partial refunds will not be made if days are missed, or unable to attend.

Enrollment: Enrollment runs September through June, a 30 day notice is required when leaving program.
Tuition (for administrative use only)
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Name*

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Drivers License Number*
Todays Date:*

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Directors Signature

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ESTEEM GIRLS AFTER SCHOOL*

Afterschool Registration (September-June)$207.41

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Afterschool STEAM Enrichment

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