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Application for Fun in the Afternoon
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Academics >  K-7 Academics >  Fun in the Afternoon >  Application for Fun in the Afternoon > 

Fun in the Afternoon Application

Statement of Purpose
The purpose of this program is to serve PCA families by providing quality educational, recreational, and social programs for students grades K-7 after the scheduled school day.
Family Status:
 Current Providence Family  New PCA Family for 2011-2012
Parent's Name(s):
Best phone #(s) to reach you:
   
E-mail Address(es):
Enrollment Data:
Student Name:
Grade for 2011-2012:
Child's PCP:
My child has the following special need(s):
My child is currently on medication(s) perscribed for long-term continuous use and/or has the following pre-existing illness, allergies, or health concerns:
My child will need:
 Part-time care  Full-time care
Please check the days your child will attend each week. If days are inconsistent, please note below:
         
 Monday  Tuesday  Wednesday  Thursday  Friday
If part-time ays are inconsistent, please explain:
My child will be picked up daily at approximately:
Release Data:
My child may be released to the person(s) signing this agreement or to the following:
Name
Address:
Relationship to student:
Contact's #'s: 1st
Contact's #'s: 2nd
This person may also be contacted in case of an emergency when parent/guardian cannot be reached:
 Yes  No
Name
Address:
Relationship to student:
Contact's #'s: 1st
Contact's #'s: 2nd
This person may also be contacted in case of an emergency when parent/guardian cannot be reached:
 Yes  No
Name
Address:
Relationship to student:
Contact's #'s: 1st
Contact's #'s: 2nd
This person may also be contacted in case of an emergency when parent/guardian cannot be reached:
 Yes  No
Program Fees:
$25 fee due for each student at time of enrollment.
Payment plan:
   
 Weekly  Monthly  Annual
Payment plans must be chosen at the beginning of the school year and cannot be changed. It is most expensive to pay weekly and least expensive to pay annually.
I have read and agree to adhere to the following Providence Christian Academy Fun in the Afternoon policies and procedures.
Signature of Parent or Guardian
Date:
I agree to allow my child to participate in all activities during the Fun in the Afternoon Program, and as consideration for the benefits derived, unless the program director or his designated representatives are negligent or at fault, I absolve the program and PCA (including all representatives, agents and employees) from liability to me or my child because of injury to my child at the program or during the program activities. I further authorize the director to secure necessary emergency medical attention for my child in the event of any injury at the afterschool program if the parents or designated emergency contacts cannot be reached.
Signature of Parent or Guardian
Date:
I hereby accept that by entering my name and today's date in the 'Signature of Parent or Guardian' boxes above, I have provided a digital signature to Providence Christian Academy.
  

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