Registration Form
Weekly Cost: under 18 months $170.00 Over 18 months: $130.00
Site ID #: 1710 388 600
BERNICE’S EDUCATIONAL SCHOOL AGE CENTER, INC.
2516 W. 4TH Street, Wilm., DE 19805
[email protected]
302-651-0286 (Office) * 302-983-7983 (Cell)* 302-981-2451 (Cell) *302-656-2098 (Fax)
I agree to pay BERNICE’S EDUCATIONAL SCHOOL AGE CENTER, INC., for Purchase of Care Plus in addition to my Division of Social Services parent’s fee. I understand that both fees from Division of Social Services and my co-pay must add up to the total weekly fee charged by BESAC. It is does not total the weekly fee, I understand that I promise to pay the differences. My worker will be notified if I leave BESAC owing a balance and fail to provide a mandatory two week prior notice to remove my child(ren). My child care will be terminated for attendance at a different child care facility if I do not pay my balance and provide a two. The weekly fee will be due if I fail to provide a prior two week notice.
WHEN DONE, PLEASE PRINT OUT REGISTRATION FORM AND SEND WITH MONEY ORDER! THANK YOU!
Participant: ________________________Age_________Sex______Date___________DOB_____________ / / 2011
__________________________________________________________________________________________________________________________________________
Street City State Zip
Parent Name/Address
__________________________________________________________________________________________________________________________________________
Street City State Zip
Parent’s Employer:________________________________________________
__________________________________________________________________________________________________________________________________
Soc. Sec. # : Street Address City State Zip
EMERGENCY CONTACT other than parent
___________________________________________________________________________________________________________________________________
Street City State Zip
Below please list all pe5rsons and their relationship to the above participant to whom the participant may be released:
Photo Identification is mandatory for release to anyone other than noted herein, or no release of child
1. ________________________ Relationship: ________________________
2. ________________________ Relationship: ________________________
3. ______________________ Relationship: ________________________
Photo Release / Field Trips/Sexual Abstinence
While participating in this School Center, lots of pictures and field trips will be taken to display on our bulletin board, or in other public places, including the newspaper, television, public displays, and going on field trips. Therefore, I give permission for my child to be photographed, participate in field trips, and Sexual Abstinence program while attending our School Center. Also, these pictures may be use for publicity at the discretion of the School Center. My permission is also granted for participation of my 12 year old and up to participates in the sexual abstinence. Lastly, I give permission for my child to sleep on a cot.
________________________ ________________________
Parent’s/Guardian’s Signature Date
Weekly Cost: under 18 months $170.00 Over 18 months: $130.00
Site ID #: 1710 388 600
BERNICE’S EDUCATIONAL SCHOOL AGE CENTER, INC.
2516 W. 4TH Street, Wilm., DE 19805
[email protected]
302-651-0286 (Office) * 302-983-7983 (Cell)* 302-981-2451 (Cell) *302-656-2098 (Fax)
I agree to pay BERNICE’S EDUCATIONAL SCHOOL AGE CENTER, INC., for Purchase of Care Plus in addition to my Division of Social Services parent’s fee. I understand that both fees from Division of Social Services and my co-pay must add up to the total weekly fee charged by BESAC. It is does not total the weekly fee, I understand that I promise to pay the differences. My worker will be notified if I leave BESAC owing a balance and fail to provide a mandatory two week prior notice to remove my child(ren). My child care will be terminated for attendance at a different child care facility if I do not pay my balance and provide a two. The weekly fee will be due if I fail to provide a prior two week notice.
WHEN DONE, PLEASE PRINT OUT REGISTRATION FORM AND SEND WITH MONEY ORDER! THANK YOU!
Participant: ________________________Age_________Sex______Date___________DOB_____________ / / 2011
__________________________________________________________________________________________________________________________________________
Street City State Zip
Parent Name/Address
__________________________________________________________________________________________________________________________________________
Street City State Zip
Parent’s Employer:________________________________________________
__________________________________________________________________________________________________________________________________
Soc. Sec. # : Street Address City State Zip
EMERGENCY CONTACT other than parent
___________________________________________________________________________________________________________________________________
Street City State Zip
Below please list all pe5rsons and their relationship to the above participant to whom the participant may be released:
Photo Identification is mandatory for release to anyone other than noted herein, or no release of child
1. ________________________ Relationship: ________________________
2. ________________________ Relationship: ________________________
3. ______________________ Relationship: ________________________
Photo Release / Field Trips/Sexual Abstinence
While participating in this School Center, lots of pictures and field trips will be taken to display on our bulletin board, or in other public places, including the newspaper, television, public displays, and going on field trips. Therefore, I give permission for my child to be photographed, participate in field trips, and Sexual Abstinence program while attending our School Center. Also, these pictures may be use for publicity at the discretion of the School Center. My permission is also granted for participation of my 12 year old and up to participates in the sexual abstinence. Lastly, I give permission for my child to sleep on a cot.
________________________ ________________________
Parent’s/Guardian’s Signature Date
