Westford Partnership for Children After School Enrichment Program NABNASSET SCHOOL SESSION 4: February 29-April 29, 2016 Child’s Name: _____________________________________ Teacher’s Name:_____________________ Grade:______ Best # to Reach:____________________ Name at this #:_____________________ Participation in the WPC program(s) may involve some risk of personal injury. I hereby release and covenant to hold harmless the Recreation Dept., its agents and employees from any and all actions, claims and damages for personal injuries that my child(ren) may have sustained and/or may have incurred as a result of participation in the program(s) for the 2015-2016 school year. I, _____________________________________ (Parent/Guardian), agree to the above disclosure and have read and understand the WPC Policies listed in the Parent Handbook. Signature:____________________________________Date:______________ FIRST TIME SIGNING UP FOR THE 2015-2016 SCHOOL YEAR? PLEASE FILL OUT ALL OF THE FOLLOWING INFORMATION. FOR RETURNING PARTICIPANTS OF 2015-2016, IF ANY INFORMATION HAS CHANGED, PLEASE UPDATE BELOW. DOB:____________________ Age:____________ M/F:_________ Allergies/Medical Concerns:________________________________________________________________________________Carries EpiPen®? Y N Home Address:____________________________________________________________________ Home Phone: ________________________________________ Email: _______________________________________________________ Guardian Name: _________________________________________________ Relationship to Child: ______________________________ Work #: ______________________________ Cell #:_________________________________ Guardian Name: _________________________________________________ Relationship to Child: ______________________________ Work #: ______________________________ Cell #:_________________________________ Alternate Emergency Contact: ________________________________________ Relationship to Child: _____________________________ Home #:____________________________ Cell #:_____________________________ Each Block is $11 Mondays (8) Tuesdays (8) Wednesdays (8) Thursdays (7) Fridays (7) Session Total Block 1: 3:10-4:00 Includes Snack Circle one Homework Homework Homework Homework TGIF! Enroll full time (Mon-Fri until 5:45 p.m.) and pay only $1000/session. If using credit/debit card, pay either full amount or $500/month. Credit/debit card payments & Annual Enrollments must submit WPC Charge Card Authorization Form. Free Gym EFK : Aerospace (add $145; limit 12) Free Gym Creation Station: Robotics (add $145; limit 10) Free Gym Free Gym Block 2: 4:00-5:00 Please circle which activity you would like your child to participate in Sports Sports Sports Creative Corner TGIF! Thank goodness it’s Friday! Choice activities include crafts, sports & games, educational programming, & more! Outdoor Fun Computer Lab (Limit 10) Marvelous Mammals General Art Homework General Art Basketball Block 3: 5:00-5:45 Free Choice Free Choice Free Choice Free Choice TGIF! Multiply $11 by # of blocks child is attending Daily Total:$__________ Daily Total:$__________ Daily Total:$__________ Daily Total:$__________ Daily Total:$__________ Multiply daily totals by # of days Subtotal (Daily Total X 8): $__________________ Subtotal (Daily Total X 8): $__________________ Subtotal (Daily Total X 8): $__________________ Subtotal (Daily Total X 7): $__________________ Subtotal (Daily Total X 7): $__________________ Block Total: $ ___________ 10% Sibling Discount part time only -____________ Activity/Late Fee(s) +_______ TOTAL DUE: $____________ For Office Use Only: COPIED Date Rec’d:______/________ Rec’d:_______:_______ a.m. p.m. Rec’d By:____________________ from _________________________ Processed By:___________________ on_________/__________ Notes: METHOD OF PAYMENT Check: Payable to “Town of Westford”- CK#______________ Cash Credit/Debit Card (Rec. Dept. must have WPC Charge Card Authorization Form on file) - Please check the appropriate box below: Pay the full amount now Pay two equal installments *Activity/late fees are included in 1 st payment Annual Enrollment Signature: ___________________________________________________________________________________________ Date: _______________________________________ Start Date: _____________________ Forms released on February 8, 2016