Registration Packet

1. WASATCH EARLY LEARNING CENTER/ REFUGE ACADEMY REGISTRATION
INSTRUCTIONS FOR FILLING OUT REGISTRATION FORM
1. PLEASE PRINT CLEARLY TO ENSURE ACCURACY OF INFORMATION.
2. Please make sure that every area of the form is completely filled out. Uncompleted forms will not be
accepted.
3. All Registration Fees are due at the time of registration. (if applicable)
4. For Family information: Please ensure that both parents/guardians information is filled in. If the home
address is the same for both then filling in (same as above) is acceptable.
5. Please make sure to give us a complete address (including city and zip code) and phone numbers (to
include area codes). If you have a home telephone number please list under primary phone, if your cell
phone is your primary phone then just list under cell phone. This is important to be able to get a hold of
you in the event of an emergency and ensure that your bills or other announcements are received.
6. Please fill out driver’s license number and state as this is used for identification purposes.
7. Please fill out only TWO contacts for emergency. Please do not list yourself unless you are the only
ones to contact. Also, for specific instances if there is someone who is forbidden from picking up a child
then please indicate that. This is for the protection of your child.
8. If you are military, then please use Tricare if appropriate, for insurance name and the parents SSN
responsible for the account. Otherwise please give the information listed.
9. Please indicate whether you want your child to be photographed.
10. Please make sure that all information for the children is filled out. This includes full name, birth date,
grade, gender, and what your child prefers to be called. Also please indicate what special needs or
allergies your child has so we can help protect them. Then please indicate for which class and time you
are registering for.
11. Please initial only next to the classes you will be registering and paying for. For example: if you are
registering for Bible Explorers, extended care and kindergarten then please initial the spaces indicated
for each of these classes or programs.
12. Please indicate who is responsible for payment. that person must sign form
13. Please indicate if you received the parent handbook.
14. Please sign and date the application. Only one signature is needed.
15. Please turn in with payment and all required documentation: immunizations, physical (Kindergarten
only) and any other pertinent information.
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2. WASATCH EARLY LEARNING CENTER/ REFUGE ACADEMY REGISTRATION
FAMILY INFORMATION
Father/Guardian First Name: M.I. Last Name:
Address: City:_____________________ ST:________ Zip:________________
Occupation: Primary Phone: ( )
Employed By: Office Phone: ( )
Driver’s License Number and State: Cell Phone: ( )
Email:
Marital Status: ____ Married ____ Single ____ Divorced ____ Widowed ____ Separated
If married, are you currently married to the child’s mother? Yes No . If divorced, are you the custodial parent? Yes No
Is the person listed above allowed to pick up children? Yes No Is there any other information that would be helpful to our
management and teachings staff? _____________________________________________________________________________
________________________________________________________________________________________________________
Mother/Guardian First Name: M.I. Last Name:
Address: City:_____________________ ST:________ Zip:________________
Occupation: Primary Phone: ( )
Employed By: Office Phone: ( )
Driver’s License Number and State: Cell Phone: ( )
Email:
Marital Status: ____ Married ____ Single ____ Divorced ____ Widowed ____ Separated
If married, are you currently married to the child’s father? Yes No . If divorced, are you the custodial parent? Yes No
Is the person listed above allowed to pick up children? Yes No Is there any other information that would be helpful to our
management and teachings staff? _____________________________________________________________________________
________________________________________________________________________________________________________
EMERGENCY CONTACTS & AUTHORIZED PERSONS FOR PICKUP
Please give us the names of 2 people whom we can contact in the event of an emergency if
we cannot get a hold of you. Please include an out of area contact if available.
1st Contact/Pick-Up First Name: Last Name:
Primary Phone: ( ) Relation to Child:
[ ] Able to pick up all children in the family
[ ] Restricted from picking up the following children:
2nd Contact/Pick-Up First Name: Last Name:
Primary Phone: ( ) Relation to Child:
[ ] Able to pick up all children in the family
[ ] Restricted from picking up the following children:
*Is there anyone you are concerned about who might try to pick up your child who does
NOT have the right to take your child? No Yes ____________________________
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3. WASATCH EARLY LEARNING CENTER/ REFUGE ACADEMY REGISTRATION
PHYSICIAN AND INSURANCE INFORMATION
Pediatrician’s Name: Phone: ( )
Name of Insurance Company:
Policy Number (or SSN if Military): Group Number: _________
Medical Release for Minor child/children:
I, ______________________, Parent/Guardian of , , , a minor
child/children, hereby authorize any Medical or Surgical treatment necessary in an emergency, and in my absence, for the well being
of the above mentioned minor (s). I agree to hold Wasatch Early Learning Center, Good Foundations Academy, Refuge
Academy, all teachers and staff members, physician or hospital in treating the above mentioned minor (s), harmless. In case of
emergency, 911 will be called.
Signature: Date:
Photographs: May we take and maintain a photo of your child/children for security purposes, [ ] Yes [ ] No
craft project, bulletin board, newsletters [ ] Yes [ ] No Website [ ] Yes [ ] No
Student Information
1st Child First Name: M.I. Last Name:
Name child prefers to be called:
Child’s Address: _____ _______ City: _____________________ ST:________ Zip:________________
Gender: [ ] Male [ ] Female Date of Birth:
List any existing medical conditions, medication, allergies, and/or special attention your child may require?
What are you registering this student for? Please mark all that apply to this student.
Early Learners (for 3-4 year olds): [ ] AM (8:30 to 11:20) [ ] PM (12:30pm to 3:20pm)
Pre-Kindergarten (for 4-5 year olds): [ ] AM (8:30 to 11:20) [ ] PM (12:30pm to 3:20pm)
Kindergarten (must be 5 by Sept 1st): [ ] Half Day (8:30 to 11:20) [ ] Full Day (8:30am to 3:00 pm)
All Day Care (For 3-K) [ ] Full Day
Part Time Care (for 3-K) [ ] Part Time List hours needed.
Monday: From__________ To__________ Tuesday: From__________ To__________ Wednesday: From__________
To__________ Thursday: From__________ To__________ Friday: From__________ To__________
[ ] Bible Explorers (1st grade to 6th grade) Grade: ______
[ ] Extended Care (Before & After school Care)
[ ] Before School Care Only (6:30am-8am) [ ] After School Care Only (End of school -6:00)
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4. WASATCH EARLY LEARNING CENTER/ REFUGE ACADEMY REGISTRATION
TUITION INFORMATION & PAYMENT AND BILLING INFORMATION
The tuitions/fees will not be prorated to accommodate sickness, holidays, family vacations or school closures due to inclement
weather or situations out of W.E.L.C.’s control.
REGISTRATION FEES/STUDENT (due at registration): 10% tuition discount if paid in full by Aug 30th. (Summer camp by
June 1st). 5% (per child registered) Family discount if more than one child enrolled in school from the same family.
Wasatch Early Learning Center for preschool, kindergarten, Daycare, (non-refundable)/child: $100.00
Bible Explorers Program/ Summer Camp/child registered: $25.00
TUITION PER CLASS/STUDENT (Monthly Fee billed on the 15th of each month and due within two weeks)
Early Learners (Pre-Three Classes): hours 8:30 – 11:30am or 12:30 - 3:30pm
Cost is $75.00 per month for a total of $675.00 dollars per school year. (Total cost w/Registration= $775.00) Initials ________
Pre-Kindergarten: hours 8:30 – 11:30am or 12:30 - 3:30pm
Cost is $110.00 per month for a total of $990.00.00 dollars per school year. (Total cost w/Registration = $1090.00) Initials ________
Half-Day Kindergarten Class: hours 8:30 – 11:30am or 12:30 - 3:30pm
Cost is $165.00 per month for a total of $1485.00 dollars per school year. (Total cost w/Registration = $1585.00) Initials ________
Kindergarten Full Day Class: hours 8:30 –3:30pm
Cost is $275.00 per month for a total of $2,475.00 dollars per school year. (Total cost w/Registration = $2575.00) Initials ________
Full Day Care: includes tuition and extended care. Ages 3-7, Hours available 6am-6pm
Cost is $350.00 per month for a total of $3150.00 dollars per school year. (Total cost w/Registration = $3250.00) Initials ________
Part Time Care: (for enrolled students who need care before or after their scheduled WELC classes) In addition to tuition.
Cost is $3.50 per hour until 3:30. After 3:30 Cost is 5.00 per hour Initials ________
Drop in- Day Care: (for children over 2 years of age Initials ________
5.00 per hour provided there is availability
Bible Explorers Class:
Cost is $25.00 per month for a total of $225.00 per school year. (Total Cost w/Registration = $250.00) Initials ________
Extended Care Program/School Age (K-6th grade):
Extended care is billed $1.25 every quarter hour per student and is billed monthly. Unless otherwise arranged. Initials ________
Late Fees: To assure your children are picked up on time a late fee will be assessed at $15.00 (per-child) for every 15 min you are
late. Initials ________
No combination of programs will equal more than 19.00 per day, per child.
Please outline below whose is responsible for payment of registration, tuition and fees. Please indicate if parents are divorced and split
tuition payment or if tuition payment is the responsibility of an adult other than the parents listed above. All tuition and fees payments
for the following month are required, in advance, by the 20 of the current month. A late fee of $25 dollars will be assessed for late
payments and returned checks. Please make all checks out to WELC and include your student name on the memo line.
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5. WASATCH EARLY LEARNING CENTER/ REFUGE ACADEMY REGISTRATION
SIGNATURES AND AGREEMENTS
Transportation Release
I grant W.E.L.C./Refuge Academy permission to transport my child in any vehicle used for W.E.L.C./Refuge Academy
programs/purposes. I understand that this transportation may occur in any vehicle included. But not limited to: buses, vans, cars, or
private vehicles. I herby release W.E.L.C./Refuge Academy its employees and agents, from any liability resulting from such
transportation. For those students who may have to walk or ride across the street to the Extended Care Building.
Parent’s Signature: Date:
By signing below you are stating that this application is filled out honestly to the best of your knowledge. If you enrolled your student
in the Bible Explorers Program then you also authorize your student to be excused from Good Foundations Academy to attend
released time religious instruction at the W.E.L.C./Refuge Academy Bible Explorers Program.
All policies and procedures and conditions are explained in the W.E.L.C./Refuge Academy parent handbook.
[ ] Please check this box if you have received and read the information in the handbook.
Signature: I agree to the conditions and polices of Wasatch Early Learning Center as stated in the Parent Handbook and this
registration form.
Parent’s Signature: Date:
Parent’s Signature: Date:
Responsible Payer Signature: Date: ______
If other than Parent
NOTICE OF NONDISCRIMINATORY POLICY AS TO STUDENTS
Wasatch Early Learning Center (5099 S. 1050 W., Riverdale) admits students of any religion, race, color, national and ethnic origin to
all the rights, privileges, programs, and activities available to students at Wasatch Early Learning Center. The school does not
discriminate on the basis of religion, race, color, national and ethnic origin in administration of its programs or of its educational,
admissions, or tuition policies.
SCHOOL USE ONLY PLEASE:
DATE DOCUMENTS RECEIVED: [ ] Emergency Contact Form
_________________________________
[ ] Payment Contract
[ ] REGISTRATION FORM: [ ] Policy Manual
[ ] PAYMENT FOR REGISTRATION: [ ] IMMUNIZATIONS (KINDERGARTEN ONLY):
[ ] PHYSICAL (KINDERGARTEN ONLY):
[ ] Emergency Release Form
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6. WASATCH EARLY LEARNING CENTER/ REFUGE ACADEMY REGISTRATION
Student Information
_____Child
First Name: M.I. Last Name:
Name child prefers to be called:
Child’s Address: _____ _______ City: _____________________ ST: ________ Zip: _______________
Gender: [ ] Male [ ] Female Date of Birth:
List any existing medical conditions, medication, allergies, and/or special attention your child may require?
What are you registering this student for? Please mark all that apply to this student.
Early Learners (for 3-4 year olds): [ ] AM (8:30 to 11:20) [ ] PM (12:30pm to 3:20pm)
Pre-Kindergarten (for 4-5 year olds): [ ] AM (8:30 to 11:20) [ ] PM (12:30pm to 3:20pm)
Kindergarten (must be 5 by Sept 1st): [ ] Half Day (8:30 to 11:20) [ ] Full Day (8:30am to 3:00 pm)
All Day Care (For 3-K) [ ] Full Day
Part Time Care (for 3-K) [ ] Part Time List hours needed.
Monday: From__________ To__________ Tuesday: From__________ To__________ Wednesday: From__________
To__________ Thursday: From__________ To__________ Friday: From__________ To__________
[ ] Bible Explorers (1st grade to 6th grade) Grade: ______
[ ] Extended Care (Before & After school Care)
[ ] Before School Care Only (6:30am-8am) [ ] After School Care Only (End of school -6:00)
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7. WASATCH EARLY LEARNING CENTER/ REFUGE ACADEMY REGISTRATION
EMERGENCY CONTACTS & AUTHORIZED PERSONS FOR PICKUP
Your Name: _________________________________ Childs Name:____________________________
[ ] Adding New Contacts [ ] Removing Contacts
1st Contact/Pick-Up First Name: Last Name:
Primary Phone: ( ) Relation to Child:
[ ] Able to pick up all children in the family
[ ] Restricted from picking up the following children:
2nd Contact/Pick-Up First Name: Last Name:
Primary Phone: ( ) Relation to Child:
[ ] Able to pick up all children in the family
[ ] Restricted from picking up the following children:
*Is there anyone you are concerned about who might try to pick up your child who does
NOT have the right to take your child? No Yes ____________________________
Parent or Legal Guardian Signature: Date:
WASATCH EARLY LEARNING CENTER/ REFUGE ACADEMY REGISTRATION
EMERGENCY CONTACTS & AUTHORIZED PERSONS FOR PICKUP
Name:_________________________________ Childs Name:____________________________
[ ] Adding New Contacts [ ] Removing Contacts
1st Contact/Pick-Up First Name: Last Name:
Primary Phone: ( ) Relation to Child:
[ ] Able to pick up all children in the family
[ ] Restricted from picking up the following children:
2nd Contact/Pick-Up First Name: Last Name:
Primary Phone: ( ) Relation to Child:
[ ] Able to pick up all children in the family
[ ] Restricted from picking up the following children:
*Is there anyone you are concerned about who might try to pick up your child who does
NOT have the right to take your child? No Yes ____________________________
Parent or Legal Guardian Signature: Date:
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8. WASATCH EARLY LEARNING CENTER/ REFUGE ACADEMY REGISTRATION
Wasatch E.L.C./Refuge Academy Summer Day Camp
FAIR PLAY POLICY & BEHAVIOR POLICY
Our goal is to provide for personal growth in a safe environment. Please assist us in maintaining a safe and enjoyable
environment by following the Fair Play Policy.
Individuals using the Wasatch E.L.C. /Refuge Academy facilities are expected to:
• Wear appropriate attire in recreation facilities, this includes a shirt and shoes.
• Refrain from using profane language.
• Refrain from placing themselves and/or others at risk (i.e. hitting, fighting, biting, kicking, spitting, etc…)
• Respect one another and one another’s belongings.
• When participating in recreation programs, remain with the instructors, following directions to the best of their
ability and refrain from disrupting the class.
Persons endangering the safety of themselves or others will be removed from the program.
Other infractions of the rules will be handed as deemed necessary by the recreation staff.
Children who misbehave or break camp rules will be given a series of check marks leading up to a “strike”. We reserve
the right to bypass one or more steps in this process if a situation warrants it.
Modifications to these rules may be made to accommodate individual needs.
1st Offense: Child will be given a five (5) minute time out.
2nd Offense: Child will be given a ten (10) minute time out.
3rd Offense: A “strike” will be given.
Not cooperating while disciplined will result in additional time added to a time out.
1st Strike: Conference with Camp Director, Recreation Supervisor, child and parents.
2nd Strike: Conference with Camp Director, Recreation Supervisor, child and parents, suspension from camp for 3 days.
3rd Strike: Dismissed from camp with NO REFUND.
Parent or Legal Guardian Signature: Date:
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