ARCHDALE FRIENDS SCHOOL PROGRAM
Enrollment Information
(Please Print)
Please check the program that meets the needs of you and your child/children:
Child's Name:__________________________ Age:______ Sex: _______
Date of Birth: __________________________
Parent/Guardian Name(s):_______________________________________________
Home Address: ________________________________________________________
City :____________________________ State: ____________ Zip: _____________
Home Phone:__________________________
Cell Phone: Mom__________________ Cell Phone: Dad________________________
E-Mail Address_________________________________(look for messages from the school)
Place of Employment (mother or guardian):____________________________
Business Phone:________________
Place of Employment (father or guardian):____________________________
Business Phone:________________
Is parent/guardian a member of Archdale Friends Meeting?____________________
If you are enrolling your child in the Preschool ½ Day Program (9:00am-12:00noon**),
please check the area you are registering for: (Please choose only one area)
________Monday, Wednesday and Friday Classes
________Tuesday and Thursday Classes
________4 Day Classes (Monday – Thursday)
________5 Day Classes (Monday – Friday)
________Preschool Summer Camp (M,W,F-8 weeks)
$ 157 per month
$ 124 per month
$ 180 per month
$ 200 per month
$300 per summer session
**Lunch Bunch is an extended day program that is available for all children. Lunch
Bunch students pack their lunch each day and stay until 12:50pm. Please check the
area below to register for Lunch Bunch: (Please choose only one area)
________Monday, Wednesday and Friday Classes
________Tuesday and Thursday Classes
________4 Day Classes (Monday – Thursday)
________5 Day Classes (Monday – Friday)
$ 25 per month
$ 20 per month
$ 30 per month
$ 35 per month
For what age group will your child be eligible? (Your child must be the age of
his/her class on or before August 30 in order to enroll in that class.)
_____Toddlers _____Twos _____Threes _____Fours _____Pre-K
After School Care will be open from 2:30pm-6:00pm and will be $55.00 weekly*
Name of School:______________________________
Grade:_______________
*Full day care for holidays, teacher workdays, and snow days will be $5.00 extra for
all who attend.
School Age Summer Camp will serve rising Kindergartners through rising
7th Graders. Hours of operation are 7:30am-6:00pm.
Part-Time (3 Days a week or less, students discretion): $65.00/weekly
Full-Time (4/5 Days a week): $90.00/weekly
Enrollment Fees:
Preschool/After School
Summer
$50 for 1st child and $25 for siblings
$25.00
* I understand that the enrollment fee is non-refundable. Initial here________________
Please list people authorized to pick up your child:
__________________________
________________________________
__________________________
________________________________
__________________________
________________________________
Child's Physician: ____________________ Phone: ___________________________
Child's Dentist: ____________________ Phone: ___________________________
List any illnesses or special needs your child has:_____________________________
_______________________________________________________________________
_______________________________________________________________________
List of medications that child takes regularly:_________________________________
_______________________________________________________________________
________________________________________________________________________
List any food allergies:____________________________________________________
________________________________________________________________________
List any medicine allergies:________________________________________________
________________________________________________________________________
List any other allergies: ___________________________________________
In an emergency, who should be notified if you are not available?
__________________________
Phone: __________________________
__________________________
Phone: __________________________
__________________________
Phone: __________________________
Hospital Preference: _______________________________________________
Insurance Company: ______________________________________________
Policy # _________________________ Group # _________________________
Notification Phone #________________________________________________
List any special skills that your child may have:_______________________________
________________________________________________________________________
________________________________________________________________________
List any special interests of your child:______________________________________
_______________________________________________________________________
_______________________________________________________________________
Please give any information concerning your child which would help in your
child's experience here: (help in a certain developmental area, fears, emotional
traumas, favorite games, etc.)________________________________________________
***************Please read carefully before signing*******************
I, ___________________________parent/guardian of ___________________________ consent
for her/him to be enrolled in the Archdale Friends School Programs. I have read the general
information and policies related to the program and understand all that was written. Any
questions I had were answered to my satisfaction. I approve of the program and accept the
facilities, equipment and supervision as being satisfactory. I approve of any transportation that
will be provided by the Enrichment Program. I hereby release the Archdale Friends School from
any and all damages on behalf of the named person, which would or could be based on the
qualifications or adequacy of the supervision, facilities, or equipment used in the program. I
also consent that if the said child should become in need of medical care, I authorize staff of the
Archdale Friends Youth Enrichment Program to contact the hospital and appropriate physician
and authorize such medical care and treatment as the welfare of the child may require. I agree to
pay for all services: medical, surgical, or legal that may not be covered by my insurance carriers.
Parent/Guardian Signature: ___________________________ Date: ___________________
___________________________ Date: ___________________
*Please sign and return along with two (2) recent
pictures of your child.