ACC Registration Form

Please fill out one registration form per child

Select School

Grade Level

Student’s First Name

Student’s Last Name

Parent/Guardian’s Full Name (1)

Tel

Email

Parent/Guardian’s Full Name (2)

Tel

Email

Emergency Contact Information
The following people are authorized to pick up the child listed above and may be contacted in the event of an emergency.
Authorized Person to Pick-Up Must Be 18 Years or Older

Contact 1 Full Name

Relationship

Tel

Email

Contact 2 Full Name

Relationship

Tel

Email

Contact 3 Full Name

Relationship

Tel

Email

Medical Information

PROGRAM / ACTIVITY SELECTION FORM Please check the program(s) and the elective activities your child will be participating in.
Electives are only offered to ACC after school care students.
Registration Fee (one time fee in addition to the monthly fee, non refundable) $75

BEFORE SCHOOL CARE PROGRAM
(Breakfast included) Cost $84

YES NO

AFTER SCHOOL CARE PROGRAMS

2-Day Program – Cost $120 3-Day Program – Cost $172 5-Day Program – Cost: $228

AFTER SCHOOL CARE ADD ON ELECTIVE ACTIVITIES
(This option is only available if you have selected an after school care program)

Homework Assistance - Greek ( by certified Teacher) Cost:$72

YES NO

Homework Assistance - All other subjects ( by certified Teacher) Cost:$72

YES NO

Spanish Cost:$72

YES NO

French Cost:$72

YES NO

Piano Cost:$100

YES NO

Guitar Cost:$100

YES NO

Basketball Cost:$72

YES NO

Volleyball Cost:$72

YES NO

Soccer Cost:$72

YES NO

IMPORTANT NOTE

1. Before School Care Hours of operation:
  - PreK 7-8:00am, Academy 7-7:45am, AMC & AUC 7-8:15am
2. After School Care Hours of operation
  - PreK 3:30-6:30 pm, Academy 3-6:30 pm, AMC 4-6:30 pm, Fridays: Academy 2-6:30 pm, AMC 3-6:30 pm
3. Daily charges if not registered
  - $6 for Before School Care and $20 for After School care
4. Elective Activities Offered only to ACC students.
  - 2 sessions a week for 40 minutes on agreed days
5. All fees are non-refundable and non-transferable
6. Cancelations will be effective on the 1st day of the following month. Modifications are not valid without full payment

TERMS OF AGREEMENT & RELEASE FORM LIABILITY Financial and Enrollment Agreement

The child is not registered until the full balance including the registration fee is received.
Registration fees are per child.
All fees are non-refundable and non-transferable.
There is no credit and no make-ups for student absences or illnesses or weather.
Any outstanding balance must be paid before a child may attend the program.
Payments are applied to the oldest charges first.
10% Sibling Discount will be applied to siblings with a lesser charge.
Sibling Discount is not applied to the Registration Fee.
$20 Late Payment Fee will be applied if payment is not received by the 1st of the month.
$35 NSF Check Fee will apply when your check is returned.
$25 Late Payment Fee will be applied if the credit card on file is declined.
If payment is not received by the 10th day of the month the child will be withdrawn.
Schedules are subject to change. Elective activities are subject to closure due to low enrollment.
The ACC nor Archimedean Schools will be responsible for any lost or damaged personal property.
August fee: 1/2 of the monthly rate; November, December, January and March fee: 3/4 of the monthly rate; June fee: 1/4 of the monthly rate.
All months will be paid separately.

OPT IN RECURING PAYMENTS

I opt to make recurring monthly payments via credit card in the amount of this agreement. Credit card authorization has been submitted to the Archimedean Cashier at the time of this registration.

OPT IN MEDIA AUTHORIZATION & RELEASE FORM

I authorize Archimedean Community Center (ACC) and its employees to take and use photos and/or videos of my child in promotional, marketing and educational literature and publications. I release the ACC from any and all liability arising out of the use of my child’s photos and videos. I am participating on a voluntary basis and no compensation, fees or royalties will be paid for this use.

OPT IN AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT

I hereby give permission to the ACC Staff to take whatever emergency measures are judged necessary for the care and protection of my child(ren) while under ACC supervision. In case of a medical emergency I understand that my child will be transported to an appropriate medical facility by the local emergency unit for treatment, if the local emergency deems necessary. I understand that in some medical situations the ACC Staff will need to contact the local emergency resources before the parent/guardian. I understand that the incurred expenses will be borne by the child’s family.

INSURANCE POLICY

By selecting this button I agree to hold harmless Archimedean Schools’ Board, the Athletic Department of Archimedean Schools, the Archimedean Middle Conservatory, and the Archimedean Community Center from any direct or implied responsibility for expenses resulting from any before and after school activity injury. The Archimedean Schools’ Board, requires that the parents/guardians of all students participating in the Archimedean Community Center (ACC), have medical primary insurance coverage in place for their children on a family plan. The parent/guardian must cover all expenses in the event of an activity-related injury.

Parent/Guardian Signature

Date