2019 Southlake Tutoring Academy

Academic After School Program Registration Form

Date of Admission *
Date of Admission
Please use today's date
Child's Name *
Child's Name
Parents Name *
Parents Name
Parent 1 Phone Number *
Parent 1 Phone Number
Parent 2 Name
Parent 2 Name
Parent 2 Phone Number
Parent 2 Phone Number
Child's Home Address *
Child's Home Address
Address of Parent or Guardian (if different from Child's)
Address of Parent or Guardian (if different from Child's)
Emergency Contact *
Emergency Contact
Must be someone other than parents.
Emergency Contact Phone
Emergency Contact Phone
Emergency Contacts Address *
Emergency Contacts Address
Please list Emergency Contact's Address
Please list the name of emergency care facility, address, and phone number.
Please list name and phone number of authorized persons allowed to pick up student. IF NONE, WRITE NONE.
I give my consent for my child to be transported and supervised by Southlake Tutoring Academy employees:
Please check all that apply.
I give consent for my child to participate in the following Water activities: *
Please check all that apply.
If yes, you will be required to fill out an emergency allergy plan at the office and supply Southlake Tutoring Academy with any medication.
Name of school.
School's phone number *
School's phone number
What grade is your child in?
My Child has permission to: *
Check all that Apply.
Daily Schedule: 3:15pm – 3:30pm (Arrival & Snack time) 3:30pm – 4:30pm (Foreign Language Classes for Chinese/Spanish) 4:30pm – 5:30pm (Homework helps & Enrichment Program) 5:30pm – 6:30pm (STA Activities & Dismissal) Snacks: STA will provide nuts-free snacks at 3:15pm each day Drop off STA Staff will sign your child in at the sign–in desk each afternoon upon arrival. Early Pick-Up If your child will be leaving early, please notify STA by calling 817-251-6950 on the designated day. The staff will have your child prepared to depart at your requested time. Remember that you will still need to sign your child out. Pick-Up Sign your child out when you pick them up from STA. If someone other than yourself or the persons authorized on the registration form will be picking up your child, a written note must be submitted to the STA staff ahead of time (this can be an email). This person must also bring a photo ID with them when they pick up your child. Late Pick-Up We close promptly at 6:30pm daily. For all children not picked up by the end of the program, regular or extended hours, the following late policy will be in effect: First 5 minutes: Grace Period Each 5 minutes thereafter: $5.00 per child The late fee is in place to compensate staff members for their time. If you know you will be late, please attempt to make alternate pick-up arrangements. STA should be notified if you foresee late arrival, as it is often stressful for a child when parents are late. NOTE: When a child is not picked up in emergency situations including, but not limited to, inclement weather or natural disasters, we will follow the above “late pick-up” policy listed above starting 45 minutes from when the parent has been informed of the need for students to be picked-up. Holidays/School Closing STA Afterschool program observes the same holidays as the CISD school calendar. However, we will offer day camps with minimum enrollment of 4 kids per day with additional charges. Inclement Weather Policy In case of inclement weather conditions, STA will follow the CISD’s decisions of opening/closing. Children at Risk Parents who arrive at STA in an incapacitated condition (i.e. alcohol, drugs) present a risk to their child. The staff in charge will advise the parent of their options regarding the transportation of their child to his/her home. Some options that may be exercised are: Call another person on the child’s emergency contact list Call the other parent Call a taxi Call a nearby neighbor / friend If a reasonable conclusion cannot be reached, the parent will be advised that either Child Protective Services or the Police will be called. WATER ACTIVITIES Campers will not be participated in water activities during afterschool program TRANSPORTATION STA will ensure campers are transported safely, we will count the campers on and off the vehicles and provide booster seats for children who will require them. BABY-SITTING Employees of STA are prohibited from babysitting for families with children NOT enrolled in STA Program. COMMUNICATION We will send email notifications of any special events/scheduling changes to the parent emails on file or via Remind. CONDUCT Our Code of Conduct states that STA is committed to providing a safe and welcoming environment for all of our members and guests. To ensure safety and comfort for all, we ask individuals to act appropriately while they are in our facility or participating in an STA program. We expect persons using STA to behave in a mature and responsible way and to respect the rights and dignity of others. Our code of conduct does not permit language or action that can hurt or frighten another person or that falls below a generally accepted standard of conduct. Specifically this includes: ♣ Angry or vulgar language including swearing, name calling, and shouting; ♣ Physical contact with another person in an angry or threatening way; ♣ Any demonstration of sexual activity or sexual contact with another person; ♣ Harassment or intimidation with words, gestures, body language or other menacing behavior; ♣ Behavior which intends to or results in the theft or destruction of property; ♣ Carrying or concealing any weapons or devices that may be used as weapons. Members are responsible for their own personal comfort and safety and should ask any person whose behavior threatens their personal comfort to refrain. Staff are trained and expected to respond to any reported violation of our code of conduct. Please do not hesitate to notify a staff member if you need assistance. We want to help! STA Management will investigate all reported incidents. Dismissal from a program or termination of STA Membership privileges may result from any violation of the code of conduct. No refunds will be given. Please note that STA Staffs are not required to have specific vaccines DISABILITIES In order for STA to provide the best afterschool experience for your child, we ask that prior to registration, you consult with the STA director regarding any special needs of your child. Due to the fact that there are some medical treatments and procedures that legally STA staff is not trained nor qualified to perform, children will be enrolled on an individual basis. We will make every attempt to serve all children. MEDICATION The Medication must be given as stated on the label directions or as amended in writing by the child’s health-care professional and must be in the original container labeled with the child’s name and the date brought to the operation. The medication will not be administered after its expiration date. STA must record the full name of the Child to whom the medication was given, the name of the medication, date, time, and amount of the medication given, and full name of the employee administering the medication. We will keep all records for at least three months after administering DISCIPLINE POLICY (Please See Attached Discipline Standard Form) If your child needs to be disciplined, acceptable measures may include: stern verbal warnings, time-out from activity, and removal from activity and placed with staff away from group, suspension from STA. Behavioral guidance is intended to promote your child’s physical, intellectual, emotional, and social well being and growth. Staff shall interact with the child and one another to provide needed help, comfort, support and: o Respect personal privacy o Respect differences in cultural, ethnic, and family backgrounds o Encourage decision making abilities o Promote ways of getting along o Encourage independence and self-direction o Use consistency in applying expectations Behavioral guidance will be constructive in nature, age and stage appropriate, and will be intended to redirect children to appropriate behavior and resolve conflicts. Parents will be notified when persistent behavioral problems are identified and will include any disciplinary steps taken in response. EXPECTATIONS Good behavior will be encouraged in a positive manner. Before the first day of starting with STA, you and your child are required to read through and sign the “Parent Handbook” to confirm the receipt of the rules and policies, found in your registration packet. This way you will both be aware of the rules and consequences. The staff will work cooperatively with parents, keeping them informed of behavior problems and methods used to teach and guide them toward socially acceptable behavior. Behavior problems that cannot be resolved cooperatively will result in your child’s dismissal from STA Program. Certain abusive behaviors will result in immediate dismissal. If your child has been receiving assistance in behavior management during the school year, it is imperative that this information be shared with the STA staff. This will enable us to work more effectively and productively with your child. Emergency Preparedness Plan It is our first responsibility to move the children to a safe area known to all employees, parents, and volunteers When we evacuate children will line up in a line and walk out of the building. If children have limited mobility or otherwise need assistance, a caregiver will assist them out. If we must leave the property, we will go to the Duff’s famous wings at 2787 E. Southlake Blvd. Southlake, TX 76092. In the event of a lockdown, we will gather the children and move them to the computer room. When we evacuate or relocate, we will conduct a face count to ensure all children are present. We will use a staff member cell phone to contact local authorities, parents and licensing. When we evacuate or relocate, we will take following items with us: 1) Parent and emergency contact numbers 2) Authorization for emergency care 3) Sign-in record If you need to contact us during an emergency, please call 214-566-3421 We will provide food, water and quiet activities until the lockdown or emergency is lifted or children have been release to their parents. When you arrive at our offsite shelter, a staff member will greet you at the door and send your child out to you. We will not release children during a lockdown. Normal release procedures will resume when the lockdown is lifted. ENROLLMENT, WITHDRAWAL & PAYMENT POLICIES There are two payment options: 1) Pay the whole semester (early bird receives 5% off) 2) Make payment in 4 installments of equal amount (payment has to be made via auto draft) 3) Enrichment classes will be billed or drafted on the 1st of each month Please fill out the Auto-Draft Authorization Form at the front desk. All returned checks will incur a $20 processing fee. Any credit card draft payments returned with non-sufficient funds will incur a $20 processing fee. Any cancellation of the Auto-Draft Authorization needs to be made in writing at least two week in advance to info@southlaketutoringacademy.com , otherwise, your account will be charged automatically without notice. All withdrawals and/or refund requests must be made in writing at least 2 weeks in advance ∙ All deposits and prepaid tuitions are non-refundable, unless the program is cancelled by STA. ∙ Registration cancellations must be made 2 weeks in advance. ∙ Cancellations less than two weeks in advance will be charged a 20% processing charge in addition to the non-refundable deposit. All cancellations must be submitted in writing. NO child will be accepted into the program unless the balance has been paid in full each week NO child will be able to register without all the required paperwork filled out and submitted to STA. STA reserves the right to remove a child from any program due to behavioral or other concerns. In the event that this may occur there will be no refund given. Every attempt will be made to work with children and their families through conferences and direct communication. ∙ Talk to your child about the importance of telling you if someone does or says something that makes them feel uncomfortable. Emphasize that adults should not ask them to keep secrets from you. ∙ Explain to your child that s/he has a basic right to privacy and that no one should touch them inappropriately or compel them to touch someone else inappropriately. ∙ Instruct your child to always remain part of the group. Stress safety in numbers. ∙ Be concerned if your child suddenly becomes withdrawn or balks at attending certain activities or being around a particular person. Gently seek to find out why. ∙ Report any actions by STA staff or volunteers that you deem to be inappropriate If you have questions or concerns, please feel free to address them with the STA Director at: 682-477-4089 We look forward to a happy and safe school year with your child! Parents have the right to review a copy of our inspection report which is posted on the wall by the sign in table. If they would like to see the minimum standard, they may go to the DFPS website at www.dfps.state.tx.us You may contact the licensing office at 817-321-8604 Address: 1501 Circle Drive, Fort Worth, TX 76119
Southlake Tutoring Academy STA (After School Enrichment Program) Consent, Waiver and Release of Liability, Photo and video release On behalf of my minor child, I hereby give permission for my child to participate in the STA (After School Enrichment Program). I hereby warrant that both myself and my child are familiar with the risks associated with participation in STA activities. I acknowledge that my child’s participation in this program is wholly voluntary and is not part of the regular school curricular program. I do hereby agree and consent to my child’s participation in STA during this school year and do assume all risks and hazards which are conducted as part of the associated activities. I hereby release, absolve, indemnify, and hold blameless the STA, its officers, directors, employees, contracted employees, independent contractors, instructors, agents, organizers, and volunteers of any and all liability for damage, injury, or expense of any kind arising out of or connected with my child’s participation in STA. I understand that in case of a medical emergency, my personal medical plan will be used. As a condition of participation in the STA program by the student named in this application, I acknowledge that I have read this consent form, and knowingly, on behalf of my child, assume all of the risks associated with participating in any way in the STA program.
By writing my name below I acknowledge that all the information above is correct to the best of my knowledge. *
By writing my name below I acknowledge that all the information above is correct to the best of my knowledge.
Today's Date *
Today's Date
Please choose the two enrichment programs you would like your child to participate in as part of your tuition. *
Please select two from the list below.