After School Zone
465 Westgate Pkwy
Dothan, AL 36303
E NTRANCE D ATE : _____________________________________________________
C HILD ’ S N AME : ______________________________________________________
DOB : _________________ GRADE: _______ AGE: ________ SEX: _________
S PECIAL N EEDS : ______________________________________________________
A LLERGIES : ___________________________________________________________
C URRENTLY P RESCRIBED M EDICATION : _______________________________________
A DDRESS : ______________________________________________________
STREET
CITY
STATE
ZIP
F ATHER : ___________________________ H OME P HONE : _____________________
E MPLOYED B Y : ______________________ P HONE : _______________________
M OTHER : __________________________ H OME P HONE : _____________________
E MPLOYED B Y : ______________________ P HONE : _______________________
P ARENT E- MAIL A DDRESS : ________________________________________________________
C HILD ’ S L IVING A RRANGEMENTS : __________________________________________
P EDIATRICIAN ’ S N AME : __________________________ P HONE : ________________
EMERGENCY CONTACT OTHER THAN PARENT OR DOCTOR
N AME : _____________________________ P HONE : _________________
A DDRESS : ___________________________________________________________
R ELATIONSHIP T O C HILD : ________________________________________________
The child may be released ONLY to the person(s) signing this application and those listed
below:
NAME
PHONE #
RELATIONSHIP
P ARENT S IGNATURE _____________________________________ D ATE _______________
After School Zone
A non-profit organization operated by After School Zone, Inc.
2015-16 School Year
POLICIES & PARENT AGREEMENT
1. After School Zone serves children ages 5-13 years.
2. After School Zone will be open from school dismissal until 6:00 pm.
3. I understand After School Zone is a Christian program, including prayers and scripture as
a part of our program.
4. If my child has a “special need”, I agree to inform ASZ management of this need upon
registration.
5. I agree to pay the registration fee of $25, per child, at the time of enrollment. If I
withdraw my child from the ASZ, I understand that the registration fee is nonrefundable
and must be renewed upon re-enrollment.
6. In the case of withdrawing my child from the ASZ, I agree to give one week’s notice. If
this notice is not given, I agree to pay one week’s tuition in lieu of the notice.
7. I agree to pay, IN ADVANCE, a weekly tuition fee of $39.00 for each week.
Payment should be received no later than Monday at 6:00pm for the upcoming
week. A late fee of $25.00 will be added after 6:00pm Monday. Your child may
not be permitted to attend the ASZ unless fees are paid in full. ASZ has the
right to take legal action to recover any unpaid accounts and to recover any
fees associated with the collection of said tuition.
8. I agree that there will be no reduction in tuition for absenteeism.
9. I agree to pay a $30 fee for a returned check. ASZ will then have the right to refuse any
future check.
10. The ASZ will be open from 3:30pm until 6:00pm.
11. I understand that my child must be signed out daily and will not be allowed to exit the
building without being signed out by a parent or approved adult that I have designated
on my initial application/registration.
12. I understand my child may not be dropped off at the door when attending ASZ Day
Camp during school holidays. I agree to pay $12.00 per day, per child, in addition to
weekly tuition, when ASZ is open for Day Camp during school holidays. Day Camp hours
are 6:30am-6:00pm. (President’s Day, Labor Day, Fall Break, etc.)
13. I agree to pay a $5.00 late fee for each 15 minutes past 6:00pm that I am late picking
up/signing out my child.
14. If a child, scheduled to be picked up by ASZ from public or private school, does not need
transportation for any given day, the parent MUST NOTIFY the ASZ at least one (1) full
hour before the scheduled pickup time. Violation of this policy will result in a warning for
the first occurrence. Subsequent violation will result in a penalty of $5.00 per occurrence.
Repeat violations may result in disenrollment of the child/children. By signing this
agreement, you are giving the ASZ permission to transport your child/children to the ASZ
facility by the ASZ buses.
15. IF SCHOOL IS DISMISSED DUE TO BAD WEATHER, ASZ WILL NOT PICK UP
YOUR CHILD/CHILDREN. PARENTS WILL BE RESPONSIBLE FOR PICKING UP
THEIR CHILD/CHILDREN FROM SCHOOL.
16. Parents will be called to pick up children who become ill. Parents will have one (1) hour
to pick up the child after being called. Children with contagious diseases may not return
to the ASZ without a signed statement from a physician indicating that the child is no
longer contagious.
17. By signing this agreement, I give ASZ staff my permission to administer first aid or obtain
emergency medical treatment in the child’s best interest, in case of an emergency.
18. PLEASE BE AWARE THAT ASZ & THE FUN ZONE DOES NOT CARRY LIABILITY
INSURANCE OR ACCIDENT POLICIES. WE WILL NOT BE RESPONSIBLE FOR ACCIDENTS.
By signing this agreement, you are acknowledging this.
19. I understand that personal items, including toys, iPods/mp3 players, or handheld games
are not allowed at the ASZ. If items are brought, it will not be the responsibility
of ASZ if lost, damaged, or stolen.
20. Discipline and guidance during the ASZ is consistent and based on individual needs and
development. We will promote self-discipline and positive behavior. Physical punishment
is NEVER permitted. Instead, we use supervised ‘time-outs’. If consistent, privileges may
also be taken away. If discipline issues continue, parents will be notified immediately for
discussion with the staff/counselors.
21. Should the management of the ASZ determine for any reason, in its sole discretion, that
a child should be released from the program, the child’s enrollment may be discharged
and this agreement terminated.
22. I understand it is my responsibility as a parent/guardian to notify the ASZ Staff of any
change in contact & address information. This includes, but not limited to, name,
address, phone numbers, emergency contacts, etc. ASZ is not responsible for
consequences arising from outdated, incorrect, or missing information.
23. I understand that tuition for the ASZ program, during the school year, must be paid to
hold a child’s place on the buses or vans. If your child is absent or missing a week,
tuition is still due. We take drop-ins for the ASZ program when space is available. The
full weekly amount must be paid. We will work with parents who share custody of their
child/children.
24. To avoid any confusion between parents, staff, and children, once you have signed your
child out for the day, you must take them with you. Parents/guardians of children who
will participate in “parents’ night out” must notify staff. Children who have not been
identified as ‘staying late’ will incur a $5.00 late fee per 15 minutes after 6:00pm.
25. The parent agreement is subject to change in whole or in part by the management upon
one (1) week’s notice.
I am in full agreement to the rules & policies outlines in this agreement.
Printed name of Parent/Guardian
Signature of Parent/Guardian
Signature of ASZ Director
Date
Date
Thank you and we look forward to an enjoyable school year with your child/children!
After School Zone Program
2015-16 School Year
TRANSPORTATION RULES
Vehicle safety is something that we take very seriously at Fun Zone. We have rules to cover
some of the do’s and don’ts. Please read them and discuss them with your child.








Seat belts must be worn at all times in vans/buses. They should be ‘snug’ around the
waist. (If there are any questions about proper use of a seat belt, please make sure your
child knows what ‘snug’ is, or ask us to show proper seat belt use.)
Stay in your seat until your driver or leader opens the van/bus door.
We keep our hands and feet to ourselves.
No yelling or loud voices allowed on the vans/limo/buses.
All personal items must stay in book bags or backpacks while on the limo.
No eating or drinking on the vans/limo.
Feet do not go on the seats or against the seat in front of us.
Seat belts are safety tools. They are not to be yanked, tugged, or pulled hard.
I have read and understand all of the rules as stated. I also understand that there
may be other rules not listed that will be enforced for safety, fairness, and order. I
also state that I have gone over these rules with my child that he/she understands
them. Any infraction of these rules may result in ‘time-out’, or your child may be
prohibited from riding in our vehicles. In severe cases, or repeat occurrences,
suspension may result.
Signature of Parent/Guardian
Printed name of Parent/Guardian
Printed Child’s Name
Date
After School Zone Program
Although we do not like to hear it, there are rules in all aspects of life. Our rules here at the ASZ
are designed to maintain safety and a spirit of fairness and fun for all. Some of the rules are as
follows. Please read these and discuss them with your child.














No running inside of the building.
No gum inside Fun Zone.
No foul language or words of mean intent (slander).
No chasing or playing tag on the skate floor.
No throwing objects indoors.
No standing, walking, or climbing over tables and chairs. Feet should stay on the floor.
No leaving your group without permission.
Keep your hands and feet to yourself. Physical violence will not be tolerated and will be
disciplined in the correct manner.
Only ride roller racers by sitting down. Do not ride them with your knees or by standing.
Only go on the skate floor with skates on. Only walk on the skate floor when you are
riding a roller racer.
Hats and other headwear are not permitted while in the center.
Shoes will be worn at all times, except while using roller racers.
There will be no playing in the bathroom. They are strictly for changing and using the
bathroom.
Always be obedient and SHOW RESPECT TO ALL STAFF.
I have read and understand all of the rules as stated. I understand that there are
rules that are not listed, but will be enforced for safety, fairness, and order. I also
state that I have gone over the rules with my child and he/she understands them.
Any infraction of the rules may result in ‘time-out’. Based on the severity and
occurrence, suspension may result.
Signature of Parent/Guardian
Printed Name of Parent/Guardian
Printed Name of Child
Date
TODAY’S DATE: ________________
CHILD’S SCHOOL: _____________________________
CHILD EMERGENCY INFORMATION SHEET
CHILD’S NAME: _________________________________ DOB: _____________________
ADDRESS _________________________ CITY______________ ST___ ZIP ____________
GUARDIAN #1 NAME: __________________________ RELATIONSHIP TO CHILD__________
HOME PHONE: _______________ CELL: _______________ WORK: _______________
GUARDIAN #2 NAME: __________________________ RELATIONSHIP TO CHILD__________
HOME PHONE: _______________ CELL: _______________ WORK: _______________
IN CASE OF EMERGENCY, WHEN NEITHER PARENT/GUARDIAN CAN BE REACHED, PLEASE CONTACT:
NAME: __________________________ RELATIONSHIP TO CHILD: _____________________
HOME PHONE: _______________ CELL: ________________ WORK: _________________
FAMILY DOCTOR: __________________________ PHONE: _____________________
I GIVE PERMISSION TO AFTER SCHOOL ZONE TO USE WHATEVER EMERGENCY MEASURES ARE DEEMED
NECESSARY FOR THE CARE AND PROTECTION OF MY CHILD, ________________________, WHILE UNDER
THEIR SUPERVISION.
IT IS UNDERSTOOD, THAT IN SOME MEDICAL SITUATIONS, THE STAFF WILL NEED TO CONTACT THE LOCAL
EMERGENCY RESOURCE BEFORE THE PARENT, CHILD’S PHYSICIAN, AND/OR OTHER ADULT ACTING ON PARENT’S
BEHALF.
IN AN EMERGENCY, I UNDERSTAND THAT MY CHILD WILL BE TRANSPORTED TO FLOWERS HOSPITAL, BY THE LOCAL
EMERGENCY UNIT FOR TREATMENT, IF THE LOCAL EMERGENCY UNIT RESOURCE DEEMS IT NECESSARY.
THE CHILD WILL BE RELEASED ONLY TO THE GUARDIANS LISTED ABOVE, OR TO THE FOLLOWING PEOPLE:
NAME: _______________________________ PHONE: ___________________
NAME: _______________________________ PHONE: ___________________
NAME: _______________________________ PHONE: ___________________
Signature of Parent/Guardian
Date