NIA Fee-Based After School Application 2024-2025 edits

NIA After School Registration Form

Fee-Based Programs | 2023-2024 School Year
Child Information

All REQUIRED fields marked with *
Child's Name*

First NameLast Name
School*
Grade*
(Put "0" if Kindergarten)
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Sex*

MaleFemaleOther
Race/Ethnicity*

American Indian or Alaska NativeAsianBlack or African AmericanHispanic/LatinoNative Hawaiian or Other Pacific IslanderWhiteOther
Birth Date*

MonthDayYear
Age*
Sibling #1
Grade
Sibling #2
Grade
Parent/Guardian Information #1

(This is who we will send the invoice to)
Parent/Guardian Name*

First NameLast Name
Relationship*
Home Number*

Area CodePhone Number
Business Number

Area CodePhone Number
Cell Number*

Area CodePhone Number
E-mail*
example@example.com
Parent/Guardian Information #2
Parent/Guardian Name

First NameLast Name
Relationship
Home Number

Area CodePhone Number
Business Number

Area CodePhone Number
Cell Number

Area CodePhone Number
E-mail
Please Identify 2 People Who May Be Called for an Emergency if You Are Not Available.
Emergency Contact Name #1*

First NameLast Name
Relationship*
Home Number*

Area CodePhone Number
Business Number

Area CodePhone Number
Cell Number*

Area CodePhone Number
E-mail*
example@example.com
Emergency Contact Name #2*

First NameLast Name
Relationship*
Home Number*

Area CodePhone Number
Business Number

Area CodePhone Number
Cell Number*

Area CodePhone Number
E-mail*
example@example.com
Dismissal
Do you give your child permission to walk home alone at dismissal?*

I give my child permission to walk home alone at dismissalI DO NOT give my child permission to walk home alone at dismissal
My child will be picked up at dismissal by myself or one of the following individuals:
Permission for Pick Up: Name #1

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Permission for Pick Up: Name #2

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Photo/Video/Interview Consent
I certify that I am the parent or legal guardian of Name of child*, whose date of birth is Month/Date/Year*.
I understand that this program features special events. Reporters and photographers may be present at these special events to record them. In some cases they may interview and/or photograph children who participate in these events. These photographs, videos, and interviews will only be used to promote this program and NIA.*

I give permission for my child to be photographed or otherwise recorded during the NIA program events and activities, and for their name or likeness to be used by NIA in any medium (books, newsletters, web sites, etc.), whether now or hereafter known or developed.I DO NOT give permission for my child to be photographed or otherwise recorded during program events and activities. As a result, my child may not be able to participate in these events and activities.
Emergency Medical Care
Child's Name*

First NameLast Name
Date Signed*

MonthDayYear
Date
If my child requires emergency medical care and I cannot be reached, I give my consent to the NIA Program to obtain the necessary medical care for my child. I agree to pay all of the cost associated with the emergency medical care that my child receives. I understand that every effort will be made to contact me before and after medical care is provided.*

Yes, I agree
Following emergency medical care, my child may be released to the following people:
Medical Emergency Contact Name #1*

First NameLast Name
Relationship*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Number*

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
Medical Emergency Contact Name #2*

First NameLast Name
Relationship*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Number*

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
Health/Insurance Information
Child's Doctor*

First NameLast Name
Insurance Company*
Phone Number*

Area CodePhone Number
Policy Holder’s ID*
Doctor's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does your child have any allergies, chronic illness, or medical conditions? If yes, please describe.
Please list any medication(s) being taken.
Last Tetanus Shot*

MonthDayYear
Date
Parent/Guardian Contract & Consent
- I am enrolling my child in a full schoolyear program, from September through June. I understand that I am committing to the full year upon enrollment, and that the program is not intended to be a drop-in or month-by-month service.
- I understand that if I select a payment plan, the fees are considered an installment of the overall cost of programming for the entire enrollment period and are not directly related to the number of service days in any particular month.
- I am committing to paying program enrollment fees according to the payment plan I select at registration, and my full enrollment total is $3,300. Any missed payments will result in my child’s suspension from the program until all payments are up to date. Payments are not reduced or waived if my child is absent from program.
- Students must be picked up on time each day or have consent to walk home. I will be on-time for dismissal. Repeated lateness may jeopardize my child’s placement in the program.
- My child will be held to the same standards of behavior as during the school day. If behavior is disruptive or becomes dangerous to themselves or others, students will be given a verbal warning and/or a formal written warning and parents will be notified. Ongoing disruptive or unsafe behavior may result in removal from program.
- I understand it is inappropriate to engage with children other than my own and will refrain from doing so. If I have a concern about another participant’s behavior, I will alert the Program Director regarding the issue.
- My child may participate in a daily homework support period. I understand that it is not guaranteed that my child will have completed his/her homework during program time and that it is my responsibility to check over their work on a daily basis.
- If any personal information changes (telephone numbers, email, mailing address, health information, emergency contacts/pick-ups, etc.) I will provide the Program Director with the new information in writing.
- Any questions or concerns regarding the program will be addressed with the on-site Program Director.
Do you understand and agree to all of the above conditions in the Parent/Guardian Contract?*

Yes, I agree and I understand that this consent will be in effect as of the date of my signing this form and will continue as long as my child is enrolled in this program.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Child's Name*

First NameLast Name
Child's Class*
NIA COMMUNITY SERVICES NETWORK, 6614 11TH AVENUE, BROOKLYN, NY 11219
MICHAEL A. BOVÉ, PRESIDENT | MARY ANNE CINO, CEO
PHONE: 718.236.5266 | INFO@NIABKLYN.ORG | WWW.NIABKLYN.ORG
NIA IS A 501(C)(3) NOT-FOR-PROFIT ORGANIZATION
Payment (Please check ONLY ONE box to indicate which type of payment plan you are selecting)*
prevnext( X )
Pay Total Now$3,200.00
$100 discount applied if you are paying upfront. Original NIA program fee is $3,300. You will be sent an invoice after form submission.

Pay in 5 Equal Payments of $660 (totaling $3,300)$3,300.00
You will be billed in 5 equal payments of $660 - once upon enrollment, and in November, January, March, and May. You will be sent an invoice after form submission.

Total $0.00
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NIA After School Registration Form