Financial Agreement. (Please initial each item that appears as indication that you have read and understand each statement)
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1 Financial Agreement Child s Name: of Birth: (Please initial each item that appears as indication that you have read and understand each statement) 1) I understand that a $ Enrollment Fee and a $75.00 Enrollment Fee for each additional child is due at the time of registration. In the event that I decide not to use the facility after paying the Enrollment Fee, the fee will be forfeited to the facility. 2) 3) The Weekly tuition rate will be charged to my account and is due on the first business day of each month. A LATE FEE of $20.00 PER WEEK will be charged to my account starting on the second business day of each week. After eight consecutive without contact care will be terminated. I understand a fee of $35.00 will be charged for non-sufficient funds processed through Tuition Express. I then have one business day to pay my account in full or a late fee of $35.00 per business day will be charged to my account until the account has been paid in full. After nine consecutive late fees have been charged care will be terminated. Any past due amounts will be turned over to collections and a 40% Collection Fee will be added to your balance. 4) Should changes in tuition rates occur, I understand that I will be notified in writing in advance of all changes. 5) I understand that weekly tuition rates reflect tuition only and DOES NOT include charges for special activities such as field trip, swimming lessons, music, tumbling, etc. I will be notified in advance of any additional charges and be given the option for my child to participate in these additional activities. 6) I understand that the weekly tuition rates reflect a weekly tuition rate made payable in weekly installments. These rates reflect holiday for which the school is closed, as well as, possible time missed or absences of my child or school closure due to severe weather or illnesses. Therefore, there will be no deduction in my weekly tuition rate. 7) TCA offers two weeks per child, enrolled to use for vacation. When a child is absent for the week, a vacation week may be applied to receive a 50% discount for that week of tuition. A request has to be made in order receive credit for a vacation week. One week can be used during the months of Jan.-June, and one week can be used during the months of July-Dec. Vacation weeks are not to be used concurrently, and can only be used once every six months. Vacation weeks do not carry over or accumulate, and are to be used in bulk. Vacation weeks cannot be broken up in days. You cannot use a vacation week during the last two weeks of enrollment. 7) I understand that a yearly Curriculum Use Fee of $75.00 per child will be charged in September. If I enroll September through December, I will be charged the $75.00 Curriculum Use fee per child. If I enroll in January through April, I will be charged a $37.50 Curriculum Us fee per child. 8) I understand that a late pick up fee of $15.00 will be charged for the first 15 minutes for each child who is at the facility after hours, with an additional charge of $2.00 per minute, per child, thereafter. 9) I understand the facility must handle illness or injury in a manner which will protect the health and safety of all the children enrolled. Therefore, should my child becomes ill while at the facility, I will be notified and expected to pick up my child within 60 minutes of the notification. A late fee of $25.00 per half hour will be assessed when I exceed the time limit. 10) I understand that written notice must be given to the facility two weeks (10 days) prior to withdrawing my child. Failure to provide written notice will result in an additional one week of tuition charged to my account. Any past due amounts will be turned over to collections and a 40% Collection Fee will be added to your balance. 11) I understand that no records of my child will be release until my account is paid in full. 12) I understand that all money paid to the facility is non-refundable. 13) I do hereby agree to the conditions of this agreement and by my signature do agree to abide by all stipulations herein. Form 1005A- Treehouse
2 of Admission: Enrollment & Information Sheet Child Information Child s First Name: Last Name: DOB: Street Address: City: State: Zip: Parent Information Father/ Guardian Name: of Birth: Cell Phone: Home Phone: Work Phone: Driver s License #: State: Street Address: City: State: Zip: Mother/ Guardian Name: of Birth: Cell Phone: Home Phone: Work Phone: Driver s License #: State: Street Address: City: State: Zip: Authorized Pickup and Emergency Contact Information I understand that when my child is brought to the school, he/she must be left with a staff member. My child is authorized to leave the school at anytime with the following individuals. Individuals MUST present valid identification at time of pickup. Please list in case of emergency who to contact in order of priority: 1.) Name: 2.) Name: Relationship: Phone #: Of Birth: Street Address: City: State: Zip: Phone #: Of Birth: Street Address: City: State: Zip: Please add more authorized pickups and emergency contacts on next page. Stated No Pickup The following people are NOT allowed to pick my child under any circumstance. 1. Name: 2. Name: Relationship: _ Relationship: I certify that all the above information is true and correct to the best of my knowledge. Form Treehouse
3 Additional Authorized Pickup and Emergency Contact Information Child s Name: of Birth: I understand that when my child is brought to the school, he/she must be left with a staff member. My child is authorized to leave the school at anytime with the following individuals. Individuals MUST present valid identification at time of pickup. Please list in case of emergency who to contact in order of priority: 3.) Name: 4.) Name: Phone #: of Birth: Relationship: Phone #: of Birth: 5.) Name: 6.) Name: Phone #: of Birth: Relationship: Phone #: of Birth: 7.) Name: 8.) Name: Phone #: of Birth: Relationship: Phone #: of Birth: 9.) Name: 10.) Name: Phone #: of Birth: Relationship: Phone #: of Birth: I certify that all the above information is true and correct to the best of my knowledge. Signature of Parent of Legal Guardian Form Treehouse
4 Child s Name: of Birth: (Please initial each item that appears as indication that you have read and understand each statement.) Medical Release For my child to be enrolled, I give my consent for Treehouse Children s Academy to secure any and all necessary emergency medical care for my child and for the staff to administer First Aid or CPR as needed. In the event of critical illness or injury, the staff may transport my child to the nearest emergency room, minor emergency clinic, or call emergencey vehicles to transport my child should the need arise. Please Circle Preferred Emergency Care Facility Texas Health Presbyterian Hospital Medical Center of Lewisville 4400 Long Prarire Rd, Flower Mound, TX W. Main St., Lewisville, TX Phone Number (469) Phone Number (972) My child has been examined within the past year by a health care professional and is able to participate in the child care program. Within 12 months of admission, I will obtain a health care professional s signed statement and will submit it to the child care operation. Please fill in the health care profession information below. Name: Address: I understand that should any doubts arise concerning the health of my child, he/she will only be admitted to the facility after I have provided written approval by a health professional. Please lest any special problems that your child may have, such as allergies, existing illness, previous serious illness, injuries and hopitalizations during the past 12 months, any medication prescribed for long-term continuous use, and any other information which caregiver s should be aware of. If left blank then you are stating this is not applicable for your child. Photo Relese For my child to be enrolled, I here by give my consent for my child to be photographed and/or videotaped during their daily activities with the use of audio and video surveillance. I understand that these pphotographs and/ or video taped images of my child may be used in training videos. Treehouse Schools LLC, is very excited for the opportunity to fearure your child s photographs and/or videos in all of our facilities brochures, websites, videos, etc. If you approve of your child s involvement in these fun activities, please initial. If not, please write NO. I hereby consent to and authorize the use of and reproduction by Treehouse School LLC for brochures, internet websites, videos and all photographs taken of my minor child for any purpose, without any monetary compenstion. I hereby release, discharge and agree to save harmless Treehouse Schools LLC its legal representatives or assigns and all persons acting under its permission or authority, from any liability in connection with the use of the photographs as aforesaid or by virtue of any alteration, processing or use thereof incomposite form, whether intentional or otherwise, as well as any publication thereof. I may be provided an electronic copy of any photograph in which my minor child s image appears upon request, at the discretion of the owner. All images electronic, negatives or positives together with the prints are owned by Treehouse Schools LLC. I hereby acknowledge that I am 18 years of age or older and the parent or guardian of the minor child photgraphed, and have read and understand the terms of this release. Additional Release For my child to be enrolled, I here by give my consent for my child to participate in age appropriate water activities including but not limited to water table play, sprinkler play, and infant or toddler splash play. I acknowledge receipt of the facility s operational polices (Parent Handbook) including those for discipline and guidance. I do hereby agree to the conditions of this agreement and by my signature do agree to abide by all stipulations herin. Form Treehouse
5 Electronic Funds Transfer Authorization For Bank Accounts Child s Name of Birth: I hereby authorize Treehouse Children s Academy to initiate debit entries to my Checking or Savings Account indicated below. To properly affect the cancellation of this agreement, I am required to give one month (30 days) written notice. Credit Union Members: Please Contact your Credit Union to verify account and routing numbers for automatic payments. Account Holder s First Name Last Name Bank or Credit Union Name Street Address Cell Phone City State Zip Street Address Routing Transit Number (see sample below) City State Zip Account Number (see sample below) Checking Account OR Savings Account Signature of Account Holder Attach Voided Check Here Deposit slips not accepted Form 1006A- Treehouse
6 After School Admission Information Child s Name: Elementary School Name of Birth: Elementary School Phone Number Elementary School Street Address City State Zip Code (Please initial each item that appears as indication that you have read and understand each statement.) I give permission for my child to view PG rated movies at the facility Transportation and Field Trips For your child to be enrolled in the after school program, we require that you give consent for your child to be transported from the elementary school above. His or her immunization record s are on file at the school and all required immunization and/or tuberculosis test and vision and hearing records are current. I hereby give permission for my child attend field trips. This includes transporting to and from field trips. Field trips may include trips to local parks, swimming pool, museums or any other age appropriate activities for my child. While my child is attending the facility, the child does not have permission to walk home, be released in care of a sibling or anyone else under 18, and / or ride a city bus home. Medical Release For my child to be enrolled, I give my consent for Treehouse Children s Academy to secure any and all necessary emergency medical care for my child and the staff to administer First Aid or CPR as needed. In the event of critical illness or injury, the staff may transport my child to the nearest emergency room, minor emergency clinic, or call emergency vehicles to transport my child should the need arise. Please Circle Preferred Emergency Care Facility Texas Health Presbyterian Hospital Medical Center of Lewisville 4400 Long Prarire Rd, Flower Mound, TX W. Main St., Lewisville, TX Phone Number (469) Phone Number (972) Financial Agreement Amendment I understand that it is my responsibility to notify the facility if my school age child does not need to picked up by Treehouse Children s Academy (972) failure to call by 12:00 PM will result in a no call fee of $ On early release day you must call by 10:00 AM. I understand that if my child is enrolled in the after-school program and attends full day, then my account will be charged an additional fee to adjust my tuition rate to the current full time tuition rate. If my child attends on an early release day there will be an additional $5.00 charge. An additional $15.00 will be charged for all day care during the school year. I do hereby agree to the conditions of this agreement and by my signature do agree to abide by all stipulations herein. Form Treehouse
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