Explorers Registration Form WINTER 2014
Explorers Registration Form
WINTER 2014
Extended Care Dwight-Englewood School January 6, 2014 - March 13, 2014 Closed when school is closed
Student Information Name: ____________________________________________________
Grade _______
Contact Information Parent(s) name:__________________________________________________________________ Home phone # (mother/father):_____________________________________________________ Business phone # (mother/father):___________________________________________________ Cell phone # (mother/father):_______________________________________________________ Emergency contact person(s) and phone #s if parent is unavailable: ___________________________________________________________________ Adults, other than those listed above, who are authorized to pick up your child:________________________
Registration Agreement I have read the registration information and agree to abide by its policy and fee procedures. ______________________________________ Signature of parent or legal guardian
_________________________ Date
315 E. Palisade Ave Englewood, NJ 07631 201-569-9500 ext.2108 fax 201-569-2044
Explorers Registration Form
WINTER 2014
Extended Care Dwight-Englewood School January 6, 2014 - March 13, 2014 Closed when school is closed
Circle the days you want your child to attend.
JANUARY 2014 Monday 6 - WINTER session begins 13 20 - no school 27
Tuesday 7 14 21 28
Wednesday 8 15 22 29
Thursday 9 16 23 30
Friday 10 17 24 - Monday make-up class 31
FEBRUARY Monday
Tuesday
Wednesday
Thursday
Friday
3 10 17 - no school 24
4 11 18 - no school 25
5 12 19 26
6 13 20 27
7 14 21 - Monday & Tuesday
MARCH Monday
Tuesday
Wednesday
Thursday
Friday
3 10
4 11
5 12
6 - no enrichment
7 - no school 14
make-up class
classes: conferences
13
STUDENT NAME: PAYMENT Explorers $30.00 per DAY. Checks payable to Dwight-Englewood School. Amount enclosed $ ____________________________ CHECK#: ____________________________ OR CREDITCARD: □Visa □MasterCard □AmericanExpress NAME ON CARD _____________________________________ Card # _______________________________________ expiration date
__________
authorization code __________
_____________________________________________ Signature
_____________________________________ Date
WINTER 2014
Extended Care Dwight-Englewood School January 6, 2014 - March 13, 2014 Closed when school is closed
Student Information Name: ____________________________________________________
Grade _______
Contact Information Parent(s) name:__________________________________________________________________ Home phone # (mother/father):_____________________________________________________ Business phone # (mother/father):___________________________________________________ Cell phone # (mother/father):_______________________________________________________ Emergency contact person(s) and phone #s if parent is unavailable: ___________________________________________________________________ Adults, other than those listed above, who are authorized to pick up your child:________________________
Registration Agreement I have read the registration information and agree to abide by its policy and fee procedures. ______________________________________ Signature of parent or legal guardian
_________________________ Date
315 E. Palisade Ave Englewood, NJ 07631 201-569-9500 ext.2108 fax 201-569-2044
Explorers Registration Form
WINTER 2014
Extended Care Dwight-Englewood School January 6, 2014 - March 13, 2014 Closed when school is closed
Circle the days you want your child to attend.
JANUARY 2014 Monday 6 - WINTER session begins 13 20 - no school 27
Tuesday 7 14 21 28
Wednesday 8 15 22 29
Thursday 9 16 23 30
Friday 10 17 24 - Monday make-up class 31
FEBRUARY Monday
Tuesday
Wednesday
Thursday
Friday
3 10 17 - no school 24
4 11 18 - no school 25
5 12 19 26
6 13 20 27
7 14 21 - Monday & Tuesday
MARCH Monday
Tuesday
Wednesday
Thursday
Friday
3 10
4 11
5 12
6 - no enrichment
7 - no school 14
make-up class
classes: conferences
13
STUDENT NAME: PAYMENT Explorers $30.00 per DAY. Checks payable to Dwight-Englewood School. Amount enclosed $ ____________________________ CHECK#: ____________________________ OR CREDITCARD: □Visa □MasterCard □AmericanExpress NAME ON CARD _____________________________________ Card # _______________________________________ expiration date
__________
authorization code __________
_____________________________________________ Signature
_____________________________________ Date
