University Avenue Discovery Center
School Age Summer Camp
2016 Enrollment Form
Child
Name of Child ______________________________
Age ________
Gender___________
Birth date ____________ Grade in Fall _________ UADC Alumni Y/N
Sponsor 1 (Parent/Guardian)
Name ___________________________________ Home Phone ________________________
Home Address ________________________________________________________________
City, State, Zip ________________________________________________________________
Employer ________________________________ Work Phone ________________________
E-mail ___________________________________
Other emergency contact information (cell phone, etc.) ________________________________
Sponsor 2 (Parent/Guardian)
Name ___________________________________ Phone _____________________________
Home Address ________________________________________________________________
City, State, Zip ________________________________________________________________
Employer ________________________________ Work Phone ________________________
E-mail ___________________________________
Other emergency contact information (cell phone, etc.) ________________________________
Please indicate and food allergies or medical conditions so that we may start to prepare for the summer.
____________________________________________________________________________
____________________________________________________________________________
We (I) wish to contract for the Block Sessions indicated below. _______________________________
Parent Signature
Please circle the desired days of the week that your child(ren) will be attending, part-time day choice is
dependent on enrollment and is not guaranteed:
M
Block One
3 Days per
week
4 Days per
week
5 Days per
week
T
W
Block Two
3 Days per
week
4 Days per
week
5 Days per
week
R
F
Block Three
3 Days per
week
4 Days per
week
5 Days per
week
University Avenue Discovery Center
School Age Summer Camp
2016 Program Contract
Please keep a copy of this contract for your records.
Name of Child: ________________________________
We (I) have read and agree to the following information. Contracts may be submitted immediately and will be
locked-in as reserved spots. (The last Block’s tuition is due with the Enrollment Form as the child’s
enrollment fee, the applicable activity fees and $30.00 for purchase of a summer bus pass.)
We (I) understand that a one block minimum enrollment for the summer is required.
We (I) understand that by signing this contract, we (I) am reserving these specific blocks for the summer.
-Whether or not my child attends these blocks, I am still obligated to pay for them.
We (I) understand that the full block tuition must be paid prior to the first day of attendance for that block.
We (I) understand that written notice must be given to add days. Extra days $75, space permitting.
We (I) understand that the enrollment fee is non-refundable and is applied to the last four week block of
registered enrollment.
We (I) understand that the enrollment paperwork packet must be completed at time of enrollment. There are
two separate packets, returning student packet and new student packet.
The last Block Session’s tuition is due with the child’s enrollment. Activity fees and bus pass fees are
both due before the first block of camp.
Guardian Printed: ___________________Date ________ Guardian Printed: _____________Date __________
Guardian Printed: ___________________Date ________ Guardian Printed: _____________Date __________
UADC Summer Camp 2016 Agreement - Contract Period June 15th – August 26th, 2016
University Avenue Discovery Center 1609 University Avenue, Madison, WI 53726 (608) 233-5371
You are required to pay tuition in advance of the care given. Tuition is due on or before the Monday of the payment block. Tuition
payments received after the due dates are subject to a $35 late fee. Block tuition rates are not prorated based on start date. I
understand that by signing this contract, I am reserving the below blocks for summer camp. Whether or not my child attends these
blocks, I am still obligated to pay for them.
Child’s name:______________________ Child birthdate:_____________ Child start date____________
I/we, ______________________________and ________________________________, agree to pay tuition as detailed here. All
tuition for my child’s care and education is to be paid on or before the first day of the summer camp block.
I understand that weekly payments do not change when UADC is closed for legal holidays, in-service or cleaning days. No credit will
be given for days absent due to illness, vacations or emergencies. In addition, payments must be kept up-to-date in order for my child
to attend. Failure to keep my account current may result in fees, termination of a child’s/children’s enrollment at UADC and/or legal
action to recover unpaid tuition.
Block 1 Weekly
Schedule
UADC Weekly/Block 1 Rates for Summer Camp 2016
FULL DAYS - June 13th, 2016-July 1st, 2016
$245/week; (3-week block = $735/block)
Check appropriate box
5 days
$225/week; (3-week block = $675/block)
4 days
$210/week; (3-week = $630/block)
3 days
Activity Fee
One session - $30
Block 2 Weekly
Schedule
Check appropriate box
5 days
Two sessions - $50
All three sessions - $75
UADC Weekly/Block Rates for Summer Camp 2016
FULL DAYS – Block 2: July 4th, 2016 -July 29st, 2016
$245/week; (4-week block = $980/block)
$225/week; (4-week block = $900/block)
4 days
$210/week; (4-week = $840/block)
3 days
Activity Fee
Block 3 Weekly
Schedule
Check appropriate box
5 days
One session - $30
Two sessions - $50
All three sessions - $75
UADC Weekly/Block Rates for Summer Camp 2016
FULL DAYS – Block 3: August 1st, 2016 -August 26th, 2016
$245/week; (4-week block = $980/block)
$225/week; (4-week block = $900/block)
4 days
$210/week; (4-week = $840/block)
3 days
Activity Fee
One session - $30
Two sessions - $50
All three sessions - $75
Add a day rates: $75 for a full day
In addition to tuition, all families are expected to pay a one-time fee of $30 for a student Bus Pass and the above Activity Fee.
I/We have read the above and by my/our signature below, understand and agree to the above terms and amounts for my/our child’s
enrollment at University Avenue Discovery Center. I understand that by signing this contract, I am reserving the above blocks
for the summer. Whether or not my child attends these blocks, I am still obligated to pay for them.
Guardian Printed: ___________________Date ________ Guardian Printed: ___________________Date __________
Guardian Printed: ___________________Date ________ Guardian Printed: ___________________Date __________
DEPARTMENT OF CHILDREN AND FAMILIES
STATE OF
WISCONSIN
Division of Early Care and Education
DCF-F (CFS-0058) (R. 02/2009)
Field Trip Or Other Activity Notification / Permission –
Child Care Centers
Use of form: Use of this form is voluntary; however, completion of this form meets the requirements of DCF 250.04(6)(a)2., DCF
251.04(4)(a)4. and 251.04(6)(a)4., and DCF 252.41(4)(a)4. Personal information you provide may be used for secondary purposes
[Privacy Law, s.15.04(1)(m), Wisconsin Statutes]. This form may be used both to notify parents of the specific date, time and
destination of field trips which require the use of a vehicle and to obtain parental authorization for a child to participate in and be
transported to and from a field trip. Note: The Child Care Enrollment form also contains a section for obtaining authorization from a
parent to participate in field trips if the center chooses to use that form.
Instructions: Complete the form and submit to the parents / guardians for their signature prior to the date of the upcoming field trip.
Name – Center or Day Camp
Name – Child
University Avenue Discovery Center
Date(s) – Field Trip or Other Activity
06/15/16-08/31/16
Destination-Activities in and around the city of
Madison via Madison Metro. For example
Children’s Museum, UW Campus, Picnic
Point, Eagle Height’s Community Gardens
Name – Center or Day Camp
Departure Time
9:30am
Estimated Return Time
4:00pm
Arboretum, Madison
City Parks, Monona
Terrace, State Capita
Type of transportation:
Contracted vehicle
Center vehicle
Parent / volunteer vehicle
Public transportation
West High School
local restaurants etc
University Avenue Discovery Center
I authorize the facility listed above to take my child on a field trip or other activity on the date(s) indicated.
SIGNATURE – Parent or Guardian
Date Signed
University Avenue Discovery Center
PARENTAL AUTHORIZATIONS: Child’s Name_____________________ Date______
1.
Required signatures
A. I/We have had an opportunity to review the policies of the University Avenue Discovery Center and a summary of the
Wisconsin Rules for Licensing Day Care Centers. I/We agree to comply with all policies contained in the Center’s Policy
handbook available in the office.
___________________________
Signature
_______________________________
Signature
B. I/We grant permission for my child to participate in normal program activities away from the center. All field trips will be
made on foot, by public bus or leased vehicles. Teacher will inform parents of each trip.
___________________________
Signature
_______________________________
Signature
2. Optional Signatures
A. I/We grant permission to photograph and/or videotape my child. These pictures might be used for classroom newsletters.
___________________________
Signature
_______________________________
Signature
B. I/We grant permission to include our name, address and phone number for the classroom list distributed
to all families within each room.
___________________________
Signature
_______________________________
Signature
This facility is operated in accordance with the USDA enrollment policy which prohibits discrimination on the basis of
race, color, national origin, sex, religion, political beliefs, disability or age. Any person who believes he or she has been
discriminated against in any USDA related activity should write immediately to the USDA, Director, Office of Civil
Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (202)
720-5964.
Caregiver Handbook Agreement Form
I, _________________________________ certify that I have received the University Avenue Discovery Center
Caregiver Handbook. I have read and understand the policies contained in the Parent Handbook including:
UADC Tuition Policy:
1) Payments are due on or before the first day of attendance.
2) A late fee of $35 will be assessed for tuition that is over two weeks.
3) Tuition that is 30 days late results in a warning letter in addition to the $35 charge for late payment. Tuition
that is 60 days late results in a suspension of service via letter and/or phone call to parent(s). Tuition that is
90 days late (no attempt to pay to reinstate child attendance, no payment plan) is sent to a Collections
Agency with an additional 15% fee for services.
UADC Pick-up Policy:
1) UADC is licensed to operate between 7:15 am and 5:30 pm. Because of potential liability regarding
licensing and staff members’ personal obligations, UADC cannot accept responsibility for children after this
time.
2) If a parent is late, the person picking up the child is required to sign a late pick-up form with the number of
minutes recorded (according to the classroom clock). A late fine of $1 per minute will be assessed this fee
goes directly to the educator responsible for your child at that time.
UADC Sick Policy:
1) Criteria for Re-admission after Illness
a. Children will be re-admitted after they have been free of symptoms of illness-induced fever, vomiting or
diarrhea, or visible signs of illness for 24 hours.
b. Madison Public Health re-admission policies will be followed for contagious skin diseases which must
be treated (impetigo, conjunctivitis, scabies, lice and nits). In cases of recurring symptoms, a second
physician’s statement may be required.
c. Children should be well enough to participate fully in the program, including active play both in and out
of doors, field trips, etc.
I ______________agree to abide by the above policies in addition to all of the policies listed in the Caregiver
Handbook. Any concerns or questions regarding these policies will be delivered in writing, to the Director or
the Executive Board. Any changes to the policies will be discussed at the monthly Board meetings and will be
decided upon in that forum. Changes will be presented to all parents via e-mail or paper copy.
______________________________________
Parent Signature/Date