Christ Lutheran Costa Mesa: School Age Care Program Registration Form

School Age Care Program

Annual Financial Agreement & Registration Form
Parent Name:

First NameLast Name
Email:
example@example.com
Student Name:

First NameLast Name
Grade
Student Name:

First NameLast Name
Grade
Student Name:

First NameLast Name
Grade
Openpath Electronic Gate System
Sign up HERE to have access to our OpenPath Gate System from 7-7:45am and 3:15-6:00pm daily!
Program Options:

Please choose the program and payment option you would like by selecting the single option below you prefer:

School Age Care Program Selection: .

	1 Payment of: (3% discount)	10 Payments of: (August - May)
AM Care, 5 days (7am - 8am) $1,325 - Annual $1,285.25 - 1 Payment $132.50 - Monthly (10 Months)
PM Care, 4-5 days (Closes 6pm) $2,020 - Annual $1959.40 - 1 Payment $202 - Monthly (10 Months)
PM Care, 3 days ( Closes 6 pm) $1700 - Annual $1649 - 1 Payment $170 - Monthly (10 Months)
PM Care, 2 days ( Closes 6pm ) $1,390 - Annual $1348.30 - 1 Payment $139 - Monthly (10 Months)
AM&PM Care, 4-5 days (Open-7am, Close-6pm) $2,650 - Annual $2,570.50 - 1 Payment $265 - Monthly (10 Months)
AM&PM Care, 3 days (Open-7am, Close-6pm) $2,340 - Annual $2,269.80 - 1 Payment $234 - Monthly (10 Months)
AM&PM Care, 2 days (Open-7am, Close-6pm) $1,920 - Annual $1862.40 - 1 Payment $192 - Monthly (10 Months)

Daily / Drop-in Options & Fees

	FACTs Billing
Drop-In Care ( Registered ) $9/hr - No Prorated Hours
Holiday Break Care $45/day - No Prorated Hours

Emergency Care Rates of $13 / hour will be applied to any individuals who are not registered for SAC care but need to utilize the service.
`Please verify your payment option chosen above by checking one box:

One Payment Option: 3% Discount - Full payment Deadline is August 31st.Ten Payment Option: Paid monthly over 10 months, Begins August & Ends in May.
I authorize the monthly or one-time auto-withdrawal from my bank account, through FACTS tuition.
Parent/Guardian Signature Date: _______________________________*

Clear
School Age Care (SAC) Acknowledgements: Please check each box and sign below to verify that you have read and are in agreement with each statement.

Please check and verify agreement with each statement below:*

	Read & Verified
I will sign my child in and out of School Age Care (SAC) using my full signature.
My child will be picked up by 6:00pm. I understand that I will be billed a late charge of $1 per minute, per child after 6:00pm with no cap. These fees will be payable at the time of billing.
I understand that my child's attendance in the School Age Care Program is based upon keeping my balance current and in good standing.
I understand that my child is expected to follow the same rules regarding behavior, dress code, and cell phone/electronic game use as stated in Christ Lutheran School's Parent/Student Handbook.
I further understand that if there is a behavior/discipline issue with a child in School Age Care (SAC), the parent/guardian will be notified. If behavior/discipline continues to be a problem, he/she may be removed from the School Age Care (SAC) program at the discretion of the SAC Director.
I understand daycare rates do not include fees for Afterschool Enrichment Program Classes, Sports, or Holiday Camps.
Parent(s)/Guardians(s)whose signature(s) is/are executed on this agreement is/are personally responsible for the payment of all tuition and fees incurred. In the event of a separation or legal marriage status change, signatory(ies) is/are fully responsible for full payment. Christ Lutheran will assume no responsibility for collection of accounts from any other party who is not a signatory on this agreement.
I understand that to terminate enrollment in the School Age Care (SAC) program I must notify the School Age Care office before the 1st of the month to withdraw or change registration status.

As evidence of my signature of the Parent/Guardian, I acknowledge that I have read, understand, and agree to the previous conditions for the enrollment of the above-named student(s).
Parent/Guardian Signature Date: _______________________________*

Clear
Should be Empty:

School Age Care Program

Openpath Electronic Gate System

Program Options:

Please choose the program and payment option you would like by selecting the single option below you prefer: