Today’s Date:

(YYYY-MM-DD)

CAMPUS AFTER SCHOOL PROGRAM 2017-2018
2901 Campus Road, Brooklyn, NY 11210 / (718) 421-7575

1. Student’s Information

Name:
Sex: M F

School:
Grade:

Teacher’s Name:

Class#:

Known Allergies:
Medical Conditions/Restrictions:

Birth Date:

(YYYY-MM-DD)

2. Parent/Guardian Information

Mother

Name:

Occupation:

Address:

Apt.

Zip:

Home Phone:

Work Phone:

Cell Phone:

Carrier:

E-Mail:

Father

Name:

Occupation:

Address:

Apt.

Zip:

Home Phone:

Work Phone:

Cell Phone:

Carrier:

E-Mail:

3. Student Pick-up and Emergency Contact Information

Please list persons with phone numbers whom you give permission to pick-up your child from the program.

Please note that we will not release children to anyone not on the list without prior authorization.

Children will not be released to anyone under the age of 16.

In the event of an emergency, these people will be contacted if a parent/guardian is unavailable.

Name:

Relationship:

Phone:

Name:

Relationship:

Phone:

Name:

Relationship:

Phone:

Name:

Relationship:

Phone:

4. After School Program Monthly Fees

Monthly Fees

3 Days Per Week

4 Days Per Week

5 Days Per Week

6:00pm Dismissal

$404.00

$427.00

$450.00

7:00pm Dismissal

$454.00

$477.00

$500.00

Start Date:

(YYYY-MM-DD)

Days Attending:

M
T
W
Th
F

Fees must be paid in advance by ten post dated checks or a

credit card must be kept on file.

All transactions will be processed on the 1st of each month

Cash may be paid before check of EFT date

Monthly Fee: $

+ $280.00 registration fee.

5. Parent/Guardian Consent

In case of an emergency injury or illness, I authorize the program to call the paramedics. As legal guardian of the above listed

student, a minor, I authorize the program representative designee to consent to any x-ray, examination, anesthetic, medical

or surgical diagnosis, treatment, and/or hospital care to be rendered upon the advice of any licensed physician and/or dentist.

There will be no refund or pro-rating for absenteeism. It is our policy to charge $5.00 per quarter hour past closing time,

which is 6:00 or 7:00pm. If child is pulled out from program before end of summer no refund will be given.

Rules and regulations must be adhered to at all times.

Campus ASP Inc. reserves the right to suspend or expel a child from the program for disruptive or dangerous behavior.

Campus ASP Inc. and its employees are not responsible for personal items.

Campus ASP Inc. may at times use your child’s image on promotional items, both in print and online.

I give consent for Campus ASP Inc. to pick up my child and attend trips using our full size school buses, mini buses,

passenger vans, minivans/cars or by walking.  
Yes      No

I give my consent for my child to attend Campus ASP Inc. and participate in its activities and trips.

  Yes      No

I have read and understand the above.

Parent/Legal Guardian Signature


Date:

(YYYY-MM-DD)


After School Office: 718-421-7575

Copyright CAMPUS Inc. – 2017 ©