Beyond the Bell

Registration: Beyond the Bell

Grades: K - 5th Program Duration: 10 Months (Follows Public School Schedule) Days: Monday - Friday Time 3-5:30 pm Weekly Tuition: $120 Registration Fee: $150 (Non-Refundable) Please note: Parents are responsible for transportation to and from the program. Transportation options can be discussed privately with us.
Program Focus Areas: Facilitated by a professional with a degree in Education, .

Tutoring in Areas such as Reading, Writing, Language Arts, and Math
Child Information
Child's Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's Race/Ethnicity*

White (Non-Hispanic or Latino)White (Hispanic or Latino)Black (Non-Hispanic)Black (Hispanic or Latino)AsianAmerican Indian/ Native AlaskanNative HawaiianMultiracialPrefer not to Answer
Parent/Guardian Information
Name*

First NameLast Name
Phone Number*
E-mail*
example@example.com
Parent/Guardian Information
Name

First NameLast Name
Phone Number
Work Number
Please enter a valid phone number.
E-mail
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship
Phone Number*
Does your child need transportation? There may be an extra charge.*

YesNo
Do you receive or need subsidized tuition from Care4kids?*

YesNo
Does your child have any allergies?*

YesNo
Does the child have any chronic illness, behavorial or medical conditions? If yes, please describe.
is your child on any medications?*

YesNo
I give Five Ducks Academy and Five Ducks Foundation Permission to photograph, videotape and/or audio my child for public relations and/or marketing purposes.*

YesNo
I authorize Five Ducks staff in any emergency situation to administer basic first aid for health or welfare reasons.*

YesNo
Discipline Policy see parent handbook for more details: 1. Verbal Warning and the warning will be documented. Parents will be notified at pick-up time. 2. Written Warning: A report of the incident will be written, and parents will be notified. 3. Suspension: Suspension from the camp program will be an automatic consequence for behavior such as fist fighting, physical/verbal coercion and destruction of property. No refunds or credits will be given for time missed due to disciplinary action.*

YesNo
How did you hear about us?*

FacebookInstagramReferred by SomeoneOther
We are looking forward to having a fun summer! Once the registration form is submitted, you will receive a confirmation email with further instructions, including payment details. Please note that a $100.00 registration fee is required and is non-refundable.
Thank You!
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

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Five Ducks Enrichment Program Registration

$100.00 Quantity
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Parent/Guardian Agreement

I understand that this is not a full day program and that it is not licensed by the CT Office of Early Childhood being that it is only a two hour program.
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Registration: Beyond the Bell

Program Focus Areas: Facilitated by a professional with a degree in Education, .

Child Information

Payment Methods

Parent/Guardian Agreement