Before & After Care Registration Form

Before & After Care Registration Form

Free State Academy
Guardian Names

Primary GuardianSecondary Guardian
Primary Guardian Email *
example@example.com
Secondary Guardian Email
example@example.com
Primary Guardian Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency contact name and phone number*
First Student's Name *

First NameLast Name
Gender*
Current Grade Level*
Student's Date of Birth*

MonthDayYear
Date
Second Student's Name

First NameLast Name
Gender
Current Grade Level
Student's Date of Birth

MonthDayYear
Date
Third Student's Name

First NameLast Name
Gender
Current Grade Level
Student's Date of Birth

MonthDayYear
Date
Fourth Student's Name

First NameLast Name
Gender
Current Grade Level
Student's Date of Birth

MonthDayYear
Date
Fifth Student's Name

First NameLast Name
Gender
Current Grade Level
Student's Date of Birth

MonthDayYear
Date
How did you hear about Before & After Care at Free State Academy?*
Before Care is available from 7am-8am and After Care is available from 3pm-6pm Monday through Friday. Please indicate what DAYS & TIMES your child/ren need care. *
Name of the school your child attends. If your child requires transportation, please contact your school district to make arrangements. *
Who is approved to pick up your child from FSA?*
Please explain any medical conditions in detail. Depending on the condition, FSA may require additional information and/or documentation. What medications will be provided for FSA to have on hand for your child? (epi pen, pain medication, allergy, etc.) *
Personal Injury and Liability Waiver

I understand, by submitting this Release and Waiver of Liability to Free State Academy, also known as “FSA,” that our family is participating in activities at our own risk, and therefore release and forever discharge Free State Academy, the leadership individuals, and volunteers from any injury that I or my child/ren may suffer as a direct result of our participation in FSA. I knowingly and voluntarily enter into this agreement and hereby waive any and all rights, claims or causes of action of any kind arising out of my participation in FSA. I agree to voluntarily give up or waive any right that I otherwise have to bring a legal action against FSA for injury or property damage.
Medical Release
I give permission to Free State Academy to attend to medical situations for my child/ren. My child is in good physical condition, except for listed restrictions or allergies listed above.

Should any illness or accident occur, I will not hold liable FSA adminstrators, volunteers, teaching staff or board members for medical aid rendered if any and I will fully reimburse medical or other expenses incurred in the care of my child/ren.

Free State Academy will with its best effort contact the responsible listed parent/guardian or emergency contacts. FSA will only carry out medical responsibilities if a parent/guardian or emergency contact cannot be reached in ample time.

My child/ren may receive first aid and medical attention by a duly licensed physician. My child/ren may be admitted to a hospital in case of emergency.

If my child/ren have a fever or are ill, they will remain at home. FSA establishes the right to determine status of illness and deny attendance during illness.
Signature confirming Personal Injury and Liability Waiver and Medical Release.*

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Personal Responsibility For Property Damage
In the event that any property damage occurs to the belongings of our current building, a fellow student, volunteer, or staff member, as a result of my or my child/ren’s willful actions, neglect or recklessness, I acknowledge and agree to be held liable for any and all costs associated with any actions of neglect or recklessness.
Signature confirming Personal Responsibility For Property Damage*

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Damage/Loss Waiver
Free State Academy is not responsible for the damage or loss of personal items belonging to students, parents staff, or volunteers.
Signature confirming Damage/Loss Waiver*

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Before Care is provided from 7am-8am. After Care is provided from 3pm to 6pm at the rate of $5 per child/per hour and in full hour increments. Siblings are $3 per hour/per child.

Before &/or After Care hours will be tallied at the end of the month to determine the total amount due. Payments are due by the 15th of the following month, with the exception of May. May payments are due on the last day of Before &/or After Care at pick-up. FSA accepts cash, checks and credit/debit cards. Payments can be made in person, mailed or completed using the QR code outside the school office.

If your child needs transportation, please reach out to Bedford County Schools to make arrangements.

Withdrawals must be stated in writing TWO weeks in advance of the last date of attendance.
I agree to the tuition and payment options set forth above. An additional $25 late fee per child, per month will be added to my tuition balance due if payment is made past the 15th of the following month. (ie: September's payment is due by October 15th)
Tuition and Withdrawal Confirmation Signature *

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Signature stating agreement with policies and conditions of FSA as stated above.*

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Date Document Signed*

MonthDayYear
Date
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