Childs Information Date of Application: Desired start date:
AFTER SCHOOL PROGRAM 2015-2016 APPLICATION FOR CHILD *All information must be complete in order to enroll
Childs Information _______________________________________ Child’s Name (first & last name)
Date of Application: ________________ Desired start date:________________ ___________________________________ Nickname
_______________________________________ Name of School and Grade
___________________________________ Enrolled in daycare presently? Where?
_______________________________________ Date of Birth
___________________________________ Code Word for Pick Up
____________________ Gender (M or F)
________________________ Complex Member (Yes or No)
Family Information _________________________________ Primary/Guardian (first & last name) Parent
_________________________________ Secondary/Guardian (first & last name) Parent
_________________________________ Date of Birth
_________________________________ Date of Birth
_________________________________ Address (street # & name)
_________________________________ Address (if different from primary)
_________________________________ City, State, Zip
_________________________________ City, State, Zip (if different from primary)
_________________________________ Home Phone
_________________________________ Home Phone (if different from primary)
_________________________________ Work Phone
_________________________________ Work Phone
_________________________________ Cell Phone
_________________________________ Cell Phone
_________________________________ Email
_________________________________ Email
Emergency Contact Information – Please list at least one other person to be contacted in case of an emergency other than the child’s parents/guardian. _________________________________ First & Last Name
___________________________________ Relationship to Child
_________________________________ Address (street # & name)
___________________________________ City, State, Zip
_____________________ Home Phone
_____________________ Work Phone
________________________ Cell Phone
Pick up listPrimary and secondary guardians are authorized to pick up your child at any time. Please list any people, other than those listed on previous page, that are allowed to pick up your child from the FLYERS program. Identification and prior notification to the site coordinator will be required.
_______________________________
________________________________
First & Last Name
First & Last Name
Health & Medical Information _______________________________ _________________________________ First & Last Name List Any Health or Medical Conditions
________________________________
___________________________________ First & Last Name List Current Medications* and Side Effects
*If you child is taking medication, you must complete Authorization to Administer Medication Form. _________________________________ Physician’s Name
____________________________________ Physician’s Phone Number
List any additional information that staff need to be aware of for the well-being of your child including but not limited to any severe allergies to food, plants or insects. _________________________________________________________________________________________
_________________________________ Signature of Parent/Guardian
____________________________________ Date Revised 05/1/2015 LA
FLYERS AFTER SCHOOL PROGRAM 2015-2016 ENROLLMENT AGREEMENT
CHILDS NAME: ___________________________ SCHOOL ATTENDING:____________________________
UNDERSTANDING I understand that I am enrolling my child in the Anne Springs Close Greenway FLYERS After School Program (“Flyers Program”). I understand that my child’s records (contacts, phone numbers, emails, and authorized pickups) are my responsibility to keep current and accurate. I will update my child’s records by filling out an updated form and submitting it to the Site Coordinator or Member Services Desk at the Complex whenever there is a change. REGISTRATION FEE’S, WEEKLY PAYMENTS, LATE PAYMENTS & HOURS OF OPERATION I understand that there is an annual registration fee of $75 that is non-refundable due at the time of enrollment. FLYERS fees: $70 a week for non-members $65 a week for complex members A 10% sibling discount beginning with the second child
I am responsible for making payments on a weekly basis and that payments are due seven days prior to the program week. A $20 Late Fee will be enforced for payments not received on time. If the weekly payment is not received the prior week, my child will not be able to attend the FLYERS program during the week of non-payment. I will receive notice of non-payment and understand that my child may not attend for the week of non-payment until payment is received or accounting is contacted to set up a payment plan.
Hours of Operation are from school dismissal to 6:00 pm. A $10 Late Pick Up for every 15 minutes (6:01-6:15 = $10, 6:16-6:30 = $20) will be required to be paid on the next billing cycle each time I am late picking up my child. On the third late pick up, I understand the charges are $20 for every 15 minutes that I am late. On the fourth occurrence, I understand that my child may be removed from the program.
DISCLOSURE OF ACCOUNT INFORMATION I understand and agree that the Flyers Program may disclose account information regarding fees including the payment therefore and any delinquency to any guardian or person authorized to pick up my child as set forth in the application.
EARLY WITHDRAWAL I agree to give a two week notice in writing when withdrawing my child from the program by filling out a cancellation form. During the two week notice, I agree to make scheduled FLYERS payments. WHERE TO MAKE PAYMENTS Program payments should be made at Anne Springs Close Greenway Recreation Complex. Convenient Automatic Weekly Credit Card Payments are available and encouraged. Payment by cash, check or credit card is also accepted. Please note that we cannot accept FLEX Childcare Credit Cards or DSS ABC Vouchers for payment. Credit card payments must be called in to the Member Services Desk at 803-547-4575 by Monday. The Complex is open seven days a week. I understand that full payment is due for every week during the school year; this includes partial weeks and full day weeks. Anne Springs Close Greenway will not refund due to absences, illness, inclement weather or vacations. *HOLIDAYS, TEACHER WORKDAYS & EARLY SCHOOL CLOSING I understand that there are some holidays & teachers workdays that FLYERS will not be open.
FLYERS will be open on most teacher work days. The children are required to bring their lunch to all full days. I will have to sign up two weeks in advance to secure a spot. There is no additional charge for Full days but prior reservations and account update are mandatory, so I will need to plan ahead. Full day sites will be posted in advance. FLYERS will be operating on a half day schedule (dismissal – 6 p.m.) on the following days: December 22, 2015 May 25th, 2016
FLYERS will not be in session on the following days: September 7, 2015 January 1, 2016 November 25-27, 2015 February 15, 2016 December 23-25, 2015 March 25, 2016 May 26-27, 2016 FLYERS will be operating on a full day (7 a.m. – 6 p.m.) schedule on the following days: October 23, 2015 February 12, 2016 December 28-31, 2015 March 28-April 1, 2016 January 4, 2016 April 22, 2016 January 18, 2016 I understand that if school is closed early or closed for the day due to inclement weather, the FLYERS program will not meet. Anne Springs Close Greenway will not refund for absences due to illness or inclement weather.
SCHOOL FURLOUGH DAYS In the event of Furlough Days through Fort Mill School District where the schools are closed, Anne Springs Close Greenway will do everything possible to offer FLYERS at an alternative site, however there will be no guarantee that FLYERS will be in session during Furlough Days. Anne Springs Close Greenway will notify parents with the alternative sites.
ABSENCES DURING PROGRAM I understand that in the event of any absences during program hours, I will be responsible for fees for time reserved, not for actual time spent at the program. This would include any vacation time. AUTHORIZED PICK UP I understand that my child will be released to any authorized person listed on the application. Each authorized person must show a form of identification and sign my child out daily. My child may be released at any time to any person listed as a guardian or person authorized to pick up as set forth in the application or other written authorization from listed guardian. PERMISSIONThe FLYERS program provides as many fun and enriching activities as possible. This will include field trips to various destinations around the Anne Close Springs Greenway and the swimming pool at the Complex on the Greenway in addition to others. The FLYERS program will arrange all transportation to and from each field trip and prior notice will go out to all parents. Please initial each item ______I hereby give my child permission to participate in all activities of the program including swimming and field trips. ______I give my child permission to leave the program site for trips in a school activity bus or chartered transportation to off-site locations and enrichment programs. I understand that I will be notified before each activity. ______I give my child permission to walk to points of interest in close proximity to the program site under FLYERS supervision. ______I give permission to have my child appear in any ASC Greenway media coverage or brochures. _____I give my child permission to watch PG movies.
MEDICAL CERTIFICATION AND AUTHORIZATION I certify that my child is of good mental and physical health and I am not aware of any health or physical limitations that would interfere with participation in the Flyers Program. I have disclosed all my child’s severe allergies to food, plants or insects. I give permission to authorize emergency care to my child in the event that neither I nor the physician can be contacted and accept financial responsibility for such services. I understand that I will have to
sign a medication authorization form before any medication can be administered (except during an emergency). FLYERS staff will not administer shots (other than an epi pen) or suppositories. STAFFING I understand that FLYERS is not staffed to serve children who need one on one direct care. We do our best to maintain the child to staff ratio of 12 to 1 at all times. All children who attend FLYERS must be able to use the toilet without assistance.
FLYERS BEHAVIOR POLICY I understand that my child will have to abide by the FLYERS policies and procedures to ensure that each participant remains safe and can have a positive experience. My child will be taken away from activities when he/she cannot behave in a safe, expected and kind manner. I will be informed of unacceptable behavior and asked to sign a discipline form. I understand that fighting of any kind will not be tolerated and will result in an automatic suspension. If behavior continues to be a problem, the Site Coordinator will have the discretion to suspend my child from the program. If behavior does not improve, as a last resort, my child will be removed from the program. FLYERS staff do not use corporal punishment. WAIVER AND RELEASE The Flyers Program is well child-proofed and the children are consistently well supervised. However, accidents do happen. The undersigned(s) personally and on behalf of the child assume(s) all risk of injury or harm to the child associated with participation in the Flyers Program and agree(s) to release, indemnify, defend and forever discharge the Flyers Program, Anne Springs Close Greenway and Leroy Springs & Company, Inc. and it's staff, employees, volunteers and agents of and from all liability, claims, demands, damages, costs, expenses, actions and causes of action in respect of death, injury, loss or damage to the child, or by the child, howsoever caused, arising or to arise by reason of or during the child's participation in the Flyers Program, unless primarily caused by the negligence of the Flyers Program.
INSURANCE I, the undersigned, Parent or Legal Guardian of the registered participant, certify that the named participant is covered by an insurance program with ___________________Company, which will compensate for injuries incurred while participating in Flyers Program activities. I am a lawful parent and/or guardian of the child set forth herein and consent to the child’s participation in the Flyers Program. By signing this agreement, I understand and agree to the terms and conditions set forth upon this agreement. Father/Guardian Signature & Date_________________________________________________________ Mother/Guardian Signature & Date ________________________________________________________ *Dates are subject to change
revised 05/1/2015 LA
FLYERS PROGRAM AUTHORIZATION TO ADMINISTER PRESCRIBED OR NON-PRESCRIBED MEDICATION TO PARTICIPANT WHILE IN THE FLYERS PROGRAM.
Name of Child: ____________________________ I hereby request the FLYERS Staff, through its designated authority, to administer the medication herewith provided according to the instructions contained on this form, to my child. Prescription drugs and other medication required by your child must be in the original container and clearly labeled with the child’s name and dosage schedule, and must have written directions for administering the medication. Please enclose medication in a labeled zip lock bag. Name of Medication: _______________________________________________ Dosage: _________________________________________________________ Time Medication is to be given: _______________________________________ Possible side effects, if any: __________________________________________ Physician’s Name: _________________________________________________ Physician’s Address: _______________________________________________ Physician’s Phone: _________________________________________________
Date: _______________ Signature of Parent/Guardian____________________________________
FLYERS PHOTO/IMAGE/SOUND RELEASE
CHILD’S NAME_________________________________________________________________________ I hereby grant permission, without reservation, to Anne Springs Close Greenway the unqualified right and permission to take and to use photographs and/or sound image/recordings of me or that of a child of whom I am the legal guardian, and to describe, same for the promotion of announcing, advertising and marketing the activities of Anne Springs Close Greenway and/or the Flyers after school program. I fully understand that no monetary payment will be made to me for such uses as described above. I release Anne Springs Close Greenway, its officers, directors, agents, employees, volunteers, licensees, assignees, successors and those acting upon their authority, from all claims which I may have, or might have, for any cause of action arising out of the taking and/or use of the photographs and/or sound/image recordings. Parent/Guardian Name (print name)____________________________________________________________ Parent/Guardian Signature______________________________________________________Date____________________ Email address_____________________________________________________________________________
FLYERS AUTOMATIC CREDIT CARD PAYMENT PROGRAM 2015-2016 Please note a new form must be filled out for the fall session. Previous auto draft forms will not apply. Anne Springs Close Greenway is pleased to offer you the pre-authorized payment plan service for your convenience. Your FLYERS fee will be automatically charged to your credit card each week. This plan eliminates the need for you to call each week to charge your credit card and allows us to better service your account. Instructions: Complete the Automatic Credit Card Payment Authorization Form on this page and make a copy of the completed Authorization Form for your records. Auto Draft Forms can be dropped off at the Complex or mailed to (registration forms must be brought in person to Complex): Anne Springs Close Greenway P.O. Box 1209 Fort Mill, SC 29716 Attention: Erin Ciechowski, Staff Accountant [email protected] fax: (803) 547-1008 I authorize Anne Springs Close Greenway to initiate charges to my credit card account. I authorize the credit card company named to accept these charges to my credit card account. These payments will be charged as indicated below. The tuition amount and payment schedule is listed below. Note that any changes in membership status will affect your automatic credit card tuition payment. Anne Springs Close Greenway is authorized to add any applicable fee’s for late pick up’s or payments. This authorization is to remain in effect for the ASCG 2015-2016 After School FLYERS Program. To cancel this automatic payment, I must provide written notice of cancellation to ASCG not less than 10 days prior to the next scheduled payment. ASCG may terminate this payment plan upon notice of two (2) declined transactions. ASCG reserves the right to cancel this agreement with prior written notice. ASCG will notify me of any changes in the dollar amount charged to my account. ASCG shall not be liable for losses caused by the credit card company’s failure to act in accordance to this request. ASCG has the authorization to run the credit card a second time if the first time it was declined due to NSF the next business day. ______________________________ Child’s Name (Please Print)
_____________ FLYERS Site
___________________________________________________ Cardholder’s Name
_____________________________________________________________________________________________________ Home Address City State & Zip Code Phone ______________________________________________________________________________________________________ Email Address (s) Effective Dates of this Authorization: August - May, 2016 Weekly charges will be processed seven days in advance of the Monday attendance date. Member Status (Check One): ( ) Member ASCG ( ) Non-Member ASCG Type of Credit Card to be Charged (Check One): ( ) Visa ( ) MasterCard ( ) Discover ( ) American Express ______________________________________ Credit Card Number
________________________ Expiration Date (MM/YY)
_______________________________________ Customer Signature
________________________ Date
FOR OFFICE USE ONLY: Date Authorization Entered: _____________________ Completed By: _______________________________
Childs Information _______________________________________ Child’s Name (first & last name)
Date of Application: ________________ Desired start date:________________ ___________________________________ Nickname
_______________________________________ Name of School and Grade
___________________________________ Enrolled in daycare presently? Where?
_______________________________________ Date of Birth
___________________________________ Code Word for Pick Up
____________________ Gender (M or F)
________________________ Complex Member (Yes or No)
Family Information _________________________________ Primary/Guardian (first & last name) Parent
_________________________________ Secondary/Guardian (first & last name) Parent
_________________________________ Date of Birth
_________________________________ Date of Birth
_________________________________ Address (street # & name)
_________________________________ Address (if different from primary)
_________________________________ City, State, Zip
_________________________________ City, State, Zip (if different from primary)
_________________________________ Home Phone
_________________________________ Home Phone (if different from primary)
_________________________________ Work Phone
_________________________________ Work Phone
_________________________________ Cell Phone
_________________________________ Cell Phone
_________________________________ Email
_________________________________ Email
Emergency Contact Information – Please list at least one other person to be contacted in case of an emergency other than the child’s parents/guardian. _________________________________ First & Last Name
___________________________________ Relationship to Child
_________________________________ Address (street # & name)
___________________________________ City, State, Zip
_____________________ Home Phone
_____________________ Work Phone
________________________ Cell Phone
Pick up listPrimary and secondary guardians are authorized to pick up your child at any time. Please list any people, other than those listed on previous page, that are allowed to pick up your child from the FLYERS program. Identification and prior notification to the site coordinator will be required.
_______________________________
________________________________
First & Last Name
First & Last Name
Health & Medical Information _______________________________ _________________________________ First & Last Name List Any Health or Medical Conditions
________________________________
___________________________________ First & Last Name List Current Medications* and Side Effects
*If you child is taking medication, you must complete Authorization to Administer Medication Form. _________________________________ Physician’s Name
____________________________________ Physician’s Phone Number
List any additional information that staff need to be aware of for the well-being of your child including but not limited to any severe allergies to food, plants or insects. _________________________________________________________________________________________
_________________________________ Signature of Parent/Guardian
____________________________________ Date Revised 05/1/2015 LA
FLYERS AFTER SCHOOL PROGRAM 2015-2016 ENROLLMENT AGREEMENT
CHILDS NAME: ___________________________ SCHOOL ATTENDING:____________________________
UNDERSTANDING I understand that I am enrolling my child in the Anne Springs Close Greenway FLYERS After School Program (“Flyers Program”). I understand that my child’s records (contacts, phone numbers, emails, and authorized pickups) are my responsibility to keep current and accurate. I will update my child’s records by filling out an updated form and submitting it to the Site Coordinator or Member Services Desk at the Complex whenever there is a change. REGISTRATION FEE’S, WEEKLY PAYMENTS, LATE PAYMENTS & HOURS OF OPERATION I understand that there is an annual registration fee of $75 that is non-refundable due at the time of enrollment. FLYERS fees: $70 a week for non-members $65 a week for complex members A 10% sibling discount beginning with the second child
I am responsible for making payments on a weekly basis and that payments are due seven days prior to the program week. A $20 Late Fee will be enforced for payments not received on time. If the weekly payment is not received the prior week, my child will not be able to attend the FLYERS program during the week of non-payment. I will receive notice of non-payment and understand that my child may not attend for the week of non-payment until payment is received or accounting is contacted to set up a payment plan.
Hours of Operation are from school dismissal to 6:00 pm. A $10 Late Pick Up for every 15 minutes (6:01-6:15 = $10, 6:16-6:30 = $20) will be required to be paid on the next billing cycle each time I am late picking up my child. On the third late pick up, I understand the charges are $20 for every 15 minutes that I am late. On the fourth occurrence, I understand that my child may be removed from the program.
DISCLOSURE OF ACCOUNT INFORMATION I understand and agree that the Flyers Program may disclose account information regarding fees including the payment therefore and any delinquency to any guardian or person authorized to pick up my child as set forth in the application.
EARLY WITHDRAWAL I agree to give a two week notice in writing when withdrawing my child from the program by filling out a cancellation form. During the two week notice, I agree to make scheduled FLYERS payments. WHERE TO MAKE PAYMENTS Program payments should be made at Anne Springs Close Greenway Recreation Complex. Convenient Automatic Weekly Credit Card Payments are available and encouraged. Payment by cash, check or credit card is also accepted. Please note that we cannot accept FLEX Childcare Credit Cards or DSS ABC Vouchers for payment. Credit card payments must be called in to the Member Services Desk at 803-547-4575 by Monday. The Complex is open seven days a week. I understand that full payment is due for every week during the school year; this includes partial weeks and full day weeks. Anne Springs Close Greenway will not refund due to absences, illness, inclement weather or vacations. *HOLIDAYS, TEACHER WORKDAYS & EARLY SCHOOL CLOSING I understand that there are some holidays & teachers workdays that FLYERS will not be open.
FLYERS will be open on most teacher work days. The children are required to bring their lunch to all full days. I will have to sign up two weeks in advance to secure a spot. There is no additional charge for Full days but prior reservations and account update are mandatory, so I will need to plan ahead. Full day sites will be posted in advance. FLYERS will be operating on a half day schedule (dismissal – 6 p.m.) on the following days: December 22, 2015 May 25th, 2016
FLYERS will not be in session on the following days: September 7, 2015 January 1, 2016 November 25-27, 2015 February 15, 2016 December 23-25, 2015 March 25, 2016 May 26-27, 2016 FLYERS will be operating on a full day (7 a.m. – 6 p.m.) schedule on the following days: October 23, 2015 February 12, 2016 December 28-31, 2015 March 28-April 1, 2016 January 4, 2016 April 22, 2016 January 18, 2016 I understand that if school is closed early or closed for the day due to inclement weather, the FLYERS program will not meet. Anne Springs Close Greenway will not refund for absences due to illness or inclement weather.
SCHOOL FURLOUGH DAYS In the event of Furlough Days through Fort Mill School District where the schools are closed, Anne Springs Close Greenway will do everything possible to offer FLYERS at an alternative site, however there will be no guarantee that FLYERS will be in session during Furlough Days. Anne Springs Close Greenway will notify parents with the alternative sites.
ABSENCES DURING PROGRAM I understand that in the event of any absences during program hours, I will be responsible for fees for time reserved, not for actual time spent at the program. This would include any vacation time. AUTHORIZED PICK UP I understand that my child will be released to any authorized person listed on the application. Each authorized person must show a form of identification and sign my child out daily. My child may be released at any time to any person listed as a guardian or person authorized to pick up as set forth in the application or other written authorization from listed guardian. PERMISSIONThe FLYERS program provides as many fun and enriching activities as possible. This will include field trips to various destinations around the Anne Close Springs Greenway and the swimming pool at the Complex on the Greenway in addition to others. The FLYERS program will arrange all transportation to and from each field trip and prior notice will go out to all parents. Please initial each item ______I hereby give my child permission to participate in all activities of the program including swimming and field trips. ______I give my child permission to leave the program site for trips in a school activity bus or chartered transportation to off-site locations and enrichment programs. I understand that I will be notified before each activity. ______I give my child permission to walk to points of interest in close proximity to the program site under FLYERS supervision. ______I give permission to have my child appear in any ASC Greenway media coverage or brochures. _____I give my child permission to watch PG movies.
MEDICAL CERTIFICATION AND AUTHORIZATION I certify that my child is of good mental and physical health and I am not aware of any health or physical limitations that would interfere with participation in the Flyers Program. I have disclosed all my child’s severe allergies to food, plants or insects. I give permission to authorize emergency care to my child in the event that neither I nor the physician can be contacted and accept financial responsibility for such services. I understand that I will have to
sign a medication authorization form before any medication can be administered (except during an emergency). FLYERS staff will not administer shots (other than an epi pen) or suppositories. STAFFING I understand that FLYERS is not staffed to serve children who need one on one direct care. We do our best to maintain the child to staff ratio of 12 to 1 at all times. All children who attend FLYERS must be able to use the toilet without assistance.
FLYERS BEHAVIOR POLICY I understand that my child will have to abide by the FLYERS policies and procedures to ensure that each participant remains safe and can have a positive experience. My child will be taken away from activities when he/she cannot behave in a safe, expected and kind manner. I will be informed of unacceptable behavior and asked to sign a discipline form. I understand that fighting of any kind will not be tolerated and will result in an automatic suspension. If behavior continues to be a problem, the Site Coordinator will have the discretion to suspend my child from the program. If behavior does not improve, as a last resort, my child will be removed from the program. FLYERS staff do not use corporal punishment. WAIVER AND RELEASE The Flyers Program is well child-proofed and the children are consistently well supervised. However, accidents do happen. The undersigned(s) personally and on behalf of the child assume(s) all risk of injury or harm to the child associated with participation in the Flyers Program and agree(s) to release, indemnify, defend and forever discharge the Flyers Program, Anne Springs Close Greenway and Leroy Springs & Company, Inc. and it's staff, employees, volunteers and agents of and from all liability, claims, demands, damages, costs, expenses, actions and causes of action in respect of death, injury, loss or damage to the child, or by the child, howsoever caused, arising or to arise by reason of or during the child's participation in the Flyers Program, unless primarily caused by the negligence of the Flyers Program.
INSURANCE I, the undersigned, Parent or Legal Guardian of the registered participant, certify that the named participant is covered by an insurance program with ___________________Company, which will compensate for injuries incurred while participating in Flyers Program activities. I am a lawful parent and/or guardian of the child set forth herein and consent to the child’s participation in the Flyers Program. By signing this agreement, I understand and agree to the terms and conditions set forth upon this agreement. Father/Guardian Signature & Date_________________________________________________________ Mother/Guardian Signature & Date ________________________________________________________ *Dates are subject to change
revised 05/1/2015 LA
FLYERS PROGRAM AUTHORIZATION TO ADMINISTER PRESCRIBED OR NON-PRESCRIBED MEDICATION TO PARTICIPANT WHILE IN THE FLYERS PROGRAM.
Name of Child: ____________________________ I hereby request the FLYERS Staff, through its designated authority, to administer the medication herewith provided according to the instructions contained on this form, to my child. Prescription drugs and other medication required by your child must be in the original container and clearly labeled with the child’s name and dosage schedule, and must have written directions for administering the medication. Please enclose medication in a labeled zip lock bag. Name of Medication: _______________________________________________ Dosage: _________________________________________________________ Time Medication is to be given: _______________________________________ Possible side effects, if any: __________________________________________ Physician’s Name: _________________________________________________ Physician’s Address: _______________________________________________ Physician’s Phone: _________________________________________________
Date: _______________ Signature of Parent/Guardian____________________________________
FLYERS PHOTO/IMAGE/SOUND RELEASE
CHILD’S NAME_________________________________________________________________________ I hereby grant permission, without reservation, to Anne Springs Close Greenway the unqualified right and permission to take and to use photographs and/or sound image/recordings of me or that of a child of whom I am the legal guardian, and to describe, same for the promotion of announcing, advertising and marketing the activities of Anne Springs Close Greenway and/or the Flyers after school program. I fully understand that no monetary payment will be made to me for such uses as described above. I release Anne Springs Close Greenway, its officers, directors, agents, employees, volunteers, licensees, assignees, successors and those acting upon their authority, from all claims which I may have, or might have, for any cause of action arising out of the taking and/or use of the photographs and/or sound/image recordings. Parent/Guardian Name (print name)____________________________________________________________ Parent/Guardian Signature______________________________________________________Date____________________ Email address_____________________________________________________________________________
FLYERS AUTOMATIC CREDIT CARD PAYMENT PROGRAM 2015-2016 Please note a new form must be filled out for the fall session. Previous auto draft forms will not apply. Anne Springs Close Greenway is pleased to offer you the pre-authorized payment plan service for your convenience. Your FLYERS fee will be automatically charged to your credit card each week. This plan eliminates the need for you to call each week to charge your credit card and allows us to better service your account. Instructions: Complete the Automatic Credit Card Payment Authorization Form on this page and make a copy of the completed Authorization Form for your records. Auto Draft Forms can be dropped off at the Complex or mailed to (registration forms must be brought in person to Complex): Anne Springs Close Greenway P.O. Box 1209 Fort Mill, SC 29716 Attention: Erin Ciechowski, Staff Accountant [email protected] fax: (803) 547-1008 I authorize Anne Springs Close Greenway to initiate charges to my credit card account. I authorize the credit card company named to accept these charges to my credit card account. These payments will be charged as indicated below. The tuition amount and payment schedule is listed below. Note that any changes in membership status will affect your automatic credit card tuition payment. Anne Springs Close Greenway is authorized to add any applicable fee’s for late pick up’s or payments. This authorization is to remain in effect for the ASCG 2015-2016 After School FLYERS Program. To cancel this automatic payment, I must provide written notice of cancellation to ASCG not less than 10 days prior to the next scheduled payment. ASCG may terminate this payment plan upon notice of two (2) declined transactions. ASCG reserves the right to cancel this agreement with prior written notice. ASCG will notify me of any changes in the dollar amount charged to my account. ASCG shall not be liable for losses caused by the credit card company’s failure to act in accordance to this request. ASCG has the authorization to run the credit card a second time if the first time it was declined due to NSF the next business day. ______________________________ Child’s Name (Please Print)
_____________ FLYERS Site
___________________________________________________ Cardholder’s Name
_____________________________________________________________________________________________________ Home Address City State & Zip Code Phone ______________________________________________________________________________________________________ Email Address (s) Effective Dates of this Authorization: August - May, 2016 Weekly charges will be processed seven days in advance of the Monday attendance date. Member Status (Check One): ( ) Member ASCG ( ) Non-Member ASCG Type of Credit Card to be Charged (Check One): ( ) Visa ( ) MasterCard ( ) Discover ( ) American Express ______________________________________ Credit Card Number
________________________ Expiration Date (MM/YY)
_______________________________________ Customer Signature
________________________ Date
FOR OFFICE USE ONLY: Date Authorization Entered: _____________________ Completed By: _______________________________
