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Stepping Stones After School Program 2017-2018

Stepping Stones After School Program 2017 -2018. Registration Form For K-5 programs at Adams, Eisenhower, Fillmore, Garfield, Harrison, Jackson, McKinley, Truman, Washington, and Wilson Elementary Schools Space limited! Registration accepted on a first-come, first-served basis Please do not use this registration form if your child attends Hayes, Jefferson, Madison, Monroe, Smart, or Buchanan. Call 563-528-0973 for registration procedures. Stepping Stones After School Program 2017 -2018. Program Start Date: Thursday August 24th, 2017 . Student's start date: Registration must be completed by 4:00 pm on: August 24th August 11th August 28th August 18th September 5th August 25th September 11th September 1st September 18th September 8th September 25th September 15th Stepping Stones Program Sites: Adams, Eisenhower, Fillmore, Garfield, Harrison, Jackson, McKinley, Truman, Washington, and Wilson Elementa

Stepping Stones After School Program 2017-2018 Registration Form For K-5 Programs at Adams, Eisenhower, Fillmore, Garfield, Harrison, Jackson, McKinley, Truman, Washington, and Wilson Elementary Schools

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1 Stepping Stones After School Program 2017 -2018. Registration Form For K-5 programs at Adams, Eisenhower, Fillmore, Garfield, Harrison, Jackson, McKinley, Truman, Washington, and Wilson Elementary Schools Space limited! Registration accepted on a first-come, first-served basis Please do not use this registration form if your child attends Hayes, Jefferson, Madison, Monroe, Smart, or Buchanan. Call 563-528-0973 for registration procedures. Stepping Stones After School Program 2017 -2018. Program Start Date: Thursday August 24th, 2017 . Student's start date: Registration must be completed by 4:00 pm on: August 24th August 11th August 28th August 18th September 5th August 25th September 11th September 1st September 18th September 8th September 25th September 15th Stepping Stones Program Sites: Adams, Eisenhower, Fillmore, Garfield, Harrison, Jackson, McKinley, Truman, Washington, and Wilson Elementary Schools Program runs from right After School until 5:30 pm.

2 Program begins 1 hour early on Wednesdays. We reserve the right to close a Program based on inadequate enrollment (Decision will be made by August 12th, 2017 ). We reserve the right to cap any Program due to over enrollment. No PM Stepping Stones on 2 hour early outs. It's a Whole Bunch of Fun! . Student quote 2017 -2018 Enrichment Partners ISU Extension, City of Davenport Parks & Rec, Red Cross, Fees Putnam Museum, Junior Theatre, and Scott County Y $25 registration fee per family and one month/four week prepayment due prior to your child's start date. We accept cash, checks, money order, Visa, Email Mastercard, and Discover.

3 Registration fee is non-refundable. Fee Structure Staff Program fees are based on your child's fee waiver status, which will be Certified teachers and staff verified through the OST Office. **Childcare Assistance / 3rd party payment accepted. Program Highlights No fee waiver: You pay $11 per day, per child After - School care until 5:30 pm Reduced fee waiver: You pay $ per day, per child Healthy snack provided After School Fee waiver: You pay $ per day, per child Learning excursions Third party payment accepted. Must have notice of decision at Homework help time of registration stating Stepping Stones is the provider.

4 Hands-on enrichment activities DHS licensed programs Register and Pay for Stepping Stones Activities 1. Complete registration form and info/authorization form Science experiments; world language lessons; structured recreation; 2. Attach fees or call (563) 528-0973 to pay by phone yoga; art, reading, and math enrichments; and homework help 3. Mail or email forms Dropoff forms from 7:30 am - 4:00 pm. 10% Discounts* 318 East 7th Street Sibling discount Davenport, IA 52803. DCS, City of Davenport, and ISU Extension employee discount Drop box available 24 hours a day on south side of DCS. Stepping Stones staff discount administration building at 1606 Brady Street.

5 Military (Active, Retired, or Veteran; must provide ID) 4. Enrollment is available all year. Students will only start Program on *Limit of two discounts per student. Mondays. We reserve the right to temporarily suspend this policy. **DHS Child Care Assistance and Promise Jobs accepted. Documentation must be on file in our office in order for your child to start a Program . Registration Form Student's Name Date of Birth Grade Current School No Fee Waiver Reduced Fee Fee Waiver Month/Day/Year (during 2017 -18 $ Waiver $ School year) per day $ per day per day All past due balances must be paid in full in order to register student/s.

6 Days of the week your child will attend the After School Program ? M T W TH F (Please Circle Days) Student's requested start date: _____. (see chart). Parent/Guardian Name _____ Parent/Guardian Signature_____. Signature indicates you have read and understand the above information included in the parent guidelines. Address _____ City _____ State _____ Zip_____ Employer _____. Home Phone _____ Work Phone _____ Cell Phone _____ email _____. I am requesting a reduced fee or fee waiver rate? _____Yes _____No _____Initial (if not requesting a fee waiver you do not need to complete the two items below). 1.

7 The total yearly GROSS income for ALL people in the home before deductions for taxes,insurance, medical expenses, and child support is: $_____PER YEAR _____initial 2. Number of people residing in my home including all children and adults: _____ _____initial Student(s) will be removed from Program if account is 5 days delinquent from due date. Further collection action will be taken if balance is 10. days past due. PARENT / GUARDIAN SIGNATURE OF UNDERSTANDING: _____ DATE: _____. Learning excursions, homework help, hands-on enrichment activities, and structured recreation make Stepping Stones a great way for your child to spend time After School !

8 Received Parent Packet. PARENT GUARDIAN SIGNATURE AND DATE: _____. For Office Use Only Date Received_____ By_____. Total Due _____ Date Paid _____ Method of Payment _____ Check #_____ Rec'd by _____. Information/Authorization form completed _____ Parent packet provided _____ EZ Care _____. Added to Roster_____ Emailed Site _____ Registration Fee _____ Special Schedule:_____. Information/Authorization Form Stepping Stones SITE: This information will be kept confidential. Most of the information is needed for the health and safety of your youth. Other information is requested for eligibility for federal funding.

9 All questions must be answered to the best of your ability. Please note N/A if an item does not apply to your student. Thank you for your cooperation. Current Date: _____. A. Primary Information 1. Youth's Name _____ 2. Birth date: _____ Male ____ Female ____. 3. Address: _____. 4. Home Phone:_____ 5. Work Phone:_____ 6. Cell Phone: _____. 7. Home School : _____ 8. Grade:_____ 9. Parent/Guardian Name: _____. 10. Employer: _____ B. Medical/Emergency Information Please give us any information which you believe will be helpful in understanding and working with your child. ( diabetes, asthma, hyperactivity, allergies, other medical information, etc.)

10 1. Allergies: _____ 2. Medication: _____. 3. Dietary Restrictions: _____. 4. Special Conditions: _____. 5. Physical or behavioral conditions that may affect or limit full participation in classroom and outdoor activities: _____. 6. Other: _____. 7. Does your child have an up to date physical examination on file in their physician's office? YES_____ NO_____ initial: _____. 8. My student(s) immunization form is on file in the School nurse's office. YES_____ NO_____ initial: _____. 9. Student's School day health plan is not available After School . Does your child(ren) have a medical or physical condition that requires additional health documentation?


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