Fillable 2020-2021 ENROLLMENT PACKET Before and After School Program

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2020-2021 ENROLLMENT PACKET Before and After School Program

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2020-2021
ENROLLMENT PACKET
Before and After School Program
Richmond Elementary
2276 SE 41
st
Ave
Portland, OR 97214
Site Director: (503) 962-9466
(503) 953 -2031
(503)952 -6290
RichmondArt4Life@Gmail.com
www.Art4Life.net
Hours: 2:00 PM – 6:00 PM
All Days: 7:00 AM – 6:00 PM
Art4Life Monthly Fee Schedule
July 2020 - June 2021
Please fill out a Change of Schedule (COS) form by the 10th day of the month prior to the next
billing cycle to change a child’s schedule.
December and June are the only prorated months.
Days per Week
PM Only
5 Days
$443
4 Days
$356
$25 drop-in AM or PM
3 Days
$308
$50 per all day
2 Days
$256
1 Day
$159
Parent Handbook
Families can always access the parent handbook and policy guide online at www.Art4Life.Net
Many billing, scheduling and general programing questions are answered there.
Payment and Late Fees
Monthly bills are emailed and/or available for pickup at the parent sign-in at your school by the
1st of each month. Monthly payments are due on the 10th of each month.
o Please make checks payable to “Art4Life”. Parents must label all payments with the
child’s first and last names, as well as the school that he/she attends, in the “Memo”
section of the check.
o You may hand-deliver your payment to an Art4Life staff member or you can mail your
payment to our mailing address: 3405 SW Naito Parkway, Portland, Oregon 97239.
o Parents are responsible for payment of each monthly bill regardless of the child’s
attendance.
o Art4Life does not offer automatic credit card withdrawal services or credit card payments
of any kind.
o Failure to pay by the due date (the 10th of each month) will result in a $25.00 late fee.
Additional $25.00 late fees will be applied monthly until the balance is paid.
o Questions regarding billing and payment can be directed to your school’s site director or
to Art4Life.Billing@gmail.com
o There will be no refunds after the first day of school.
o There are no refunds for snow days, sick days or unexpected absences.
Contact Information for Art4Life
RichmondArt4Life@Gmail.com will be checked frequently and will be the primary source of
communication between the site director and the parents. Please be sure to supply an email
address at which you can be reached, or alert us if this is an inconvenient method of
communication for you.
RichmondArt4Life
2020-2021
Enrollment Packet
__________________________ ___________________ _____________________
Student Enrolling Date Grade 2020-2021 School Year
Schedule:
Monday Afternoon
Tuesday Afternoon
WednesdayAfternoon
Thursday Afternoon
Friday Afternoon
_________________ One-month tuition deposit of $______ is due upon registration.
Date
_________________ $100.00 nonrefundable Enrollment Fee is due upon registration.
Date
● Please notify the Director in writing no later than September 2
nd
if you would like to withdraw your
child or change his/her schedule. After that date, no refunds or credits will be granted.
● By signing below, I agree to the payment terms defined by the fee schedule.
● I understand that tuition is due by the 10th day of every month, and that a $25.00 late fee will be
imposed if tuition has not been received by the 10th of each month.
● I realize that Art4Life closes at 6:00 p.m. and I am responsible for compensating the Art4Life teacher on
duty with payment of $1.00 for every minute after 6:00 p.m. that I am late.
______________________________ _____________________
Parent or Guardian Signature Date
____________________________________ ________________________
Parent or Guardian Signature Date
Non-discrimination Statement
Art4Life is an equal opportunity program and does not discriminate in employment or the provision of services on the basis of race,
color, religion, sex, national origin, citizenship status, age, disability, political affiliation, sexual orientation, veteran status, or beliefs.
____________
____________
____________
____________
____________
Art4Life Policies
Please refer to the online parent handbook and policy guide on the Art4Life website. Many billing, scheduling
and general programming questions are answered on our website.
Schedule Changes
Art4Life is a tuition-based, non-profit organization that issues billing statements at the start of each month. We
can accommodate schedule changes if we receive written notification in the form of a Change of Schedule
(COS) by the 10th day of the month prior to the next billing cycle.COS forms can be found at the parent board.
o To change a child’s monthly schedule permanently, parents must submit a COS form by the 10th day of
the month prior to the next billing cycle.
o To change a child’s monthly schedule temporarily for a particular month, parents must submit a COS
form by the 10th day of the month prior to the next billing cycle.
o To discontinue a child’s care, parents must submit a COS form by the tenth day of the month prior to the
next billing cycle.
Verbal notifications of schedule changes will not be honored. Any other circumstances will be treated on a
case-by-case basis if discussed in advance with the Executive Director.
Payment and Late Fees
Monthly bills are emailed on the 1st of each month at the school where your child attends.
o Please make tuition checks payable to “Art4Life”. Parents must label all payments with the child’s first
and last names, as well as the school that he/she attends, in the “Memo” section of the check.
o You may hand-deliver your payment to an Art4Life staff member or you can mail your payment to our
mailing address: 3405 SW Naito Parkway, Portland, Oregon 97239.
o Parents are responsible for payment of each monthly bill regardless of the child’s attendance.
o Art4Life does not offer automatic credit card withdrawal services or credit card payments of any kind.
o Failure to pay tuition by the due date (the 10th of each month) will first result in a $25.00 late fee.
Additional $25.00 late fees will be applied monthly until the balance is paid. 
o After three months of nonpayment, all evidentiary information will be forwarded to Art4Life’s attorney
and the child will be removed from the program.
o Questions regarding billing and payment can be directed to your school’s site director or
Art4Life.Billing@gmail.com
o There will be no refunds after the first day of school.
o December and June are the only months that are prorated.
o There are no refunds for snow days, sick days or vacation days.
Scholarships
Art4Life offers partial scholarships to those families who qualify. Applications for partial scholarships are
available at the parent board. Enrollment Fees are not included in partial scholarships.
Extensive policy and procedure information is located online at www.Art4Life.net, on the parent board
located at your school or provided by request. Please sign and date below indicating that you have read and
agree to the above policies and those listed online.
___________________________________________ __________________
Parent or Guardian Signature Date
Art4Life Policies (continued)
Pick Up and Drop Off
Parents are required to sign in their child (or children, if applicable) every morning that their child attends
Art4Life. Parents are also required to sign out their child (or children, if applicable) every afternoon that their
child attends Art4Life. Any individual other than the parent picking up children must present photo ID to
an Art4Life staff member. In this event, parents must notify an Art4Life staff member and have that
person listed as being authorized to pick up their child.
Finders Fee
Your child’s school does not relay messages to Art4Life nor does it notify us when children are absent or leave
school early. It is important that all children are accounted for who are scheduled to attend Art4Life. In order
to avoid a $15 finders fee, please do the following:
o Send an email to RichmondArt4Life@Gmail.com informing us that your child will not be attending
Art4Life that day.
OR
o Write a note in the parent book located at the parent board.
OR
o Leave a voice-mail message on the Art4Life phone (503) 962-9466.
If Art4Life does not receive notification and must search for a child who was absent from school or whose
after-school plans have changed, the parents will be notified and a $15 finders fee will be imposed on the
following month’s billing statement. If Art4Life cannot confirm your child’s whereabouts within 10 minutes of
dismissal, Art4Life will call you. If no response is received from you after 15 minutes, our staff will call your
child’s emergency contacts. If after 30 minutes we have received no confirmation as to your child’s
location, Art4Life will call 911 to report a missing child.
Extensive policy and procedure information is located online, on the parent board located at your school
or provided by request.
Please sign and date below indicating that you have read, understand and agree to the above policies.
Parent or Guardian Signature Date
Child Enrollment and Authorization
Continued on back (additional signature and date)
Oregon Department of Education • Early Learning Division • Office of Child Care • www.childcareinoregon.org
TA-806 10/28/2013
Child’s Last Name Date Entered Care
___________________________________________________________________________________________________
Child’s First Name Age at Entry to Care
___________________________________________________________________________________________________
Child’s Nickname Date of Birth
ALLERGY ALERT: Does child have allergies? Yes □ No □ If yes, list all allergies on back side of form
Parent or Guardian Contact Information Email:
Name (first, last)
Relationship
Home Address
City
Zip
Home Phone
Work Phone
Employer and Work Hours
Cell Phone
Work Address
City
Zip
Name (first, last)
Relationship
Home Address
City
Zip
Home Phone
Work Phone
Employer and Work Hours
Cell Phone
Work Address
City
Zip
Required Emergency Contact Information-person other than parent or guardian that is authorized to pick up child
Phone
Relationship
Phone
Relationship
Non-Emergency Contact Information-person other than parent or guardian that is authorized to pick up child
Phone
Relationship
Phone
Relationship
Medical/Dental Contact Information
Insurance Provider and Policy Information (if applicable)
Primary Physician Name Phone
Dental Provider (if child is school-age. If none, list dental provider for child care facility) Phone
Parent or Guardian Authorization
Please list any restrictions to permission of the following:
□ My child may be taken on field trips or excursions by bus or private motor vehicle, as well as on neighborhood walking excursions
under required supervision (see special transportation arrangements section on back of form).
□ My child may participate in swimming or other water activities under required supervision (OCC requires approved lifeguard).
□ My child may be photographed for publicity or news purposes □ On-site □ Off-site
□ My child may be given non-prescribed medication as indicated on the container. This may include sunscreen, children’s pain
reliever, antibacterial first aid cream, and diapering ointment. Syrup of ipecac may be administered if deemed necessary by the
poison control operator. The child’s parent or guardian will be contacted prior to administering non-prescription pain relievers.
Prescription medications must be current and a permission slip is required per each medication.
In an emergency, the child care facility has my permission to call an ambulance, or take my child to any available physician or hospital at
my expense to obtain medical treatment. In most emergencies, 911 is called and the child is transported to the nearest hospital and
treated by the on-call physician. The parent or guardian of the child is notified as soon as possible.
Parent/Guardian Signature _________________________________________________ Date__________________________
Child
Information
Has your child previously been in child care? If yes, what type of care and for how long?
Reason for requesting care
Child General Information- please include all information that will assist us in providing quality care for your child
Likes and Dislikes
Eating Habits and Schedule
Sleeping Habits and Schedule
Play
Fears
Special Words and their Meanings
Child Medical Information
Does your child have allergies?
Yes No
Has your child had chickenpox?
Yes No
List all allergies or other health problems, including instructions for providing best possible care in regard to stated conditions.
Do any of the medical conditions restrict the child's activities?
Other Children in Home
Name (first, last)
Nickname
Age
Gender
Name (first, last)
Nickname
Age
Gender
Name (first, last)
Nickname
Age
Gender
Name (first, last)
Nickname
Age
Gender
Special Transportation Arrangements
Office of Child Care requires a written plan of the transportation arrangements between the child care facility and the parent or
guardian of the child for extracurricular activities. The following indicates the child care facility's transportation plan:
______________(Child) attends ______________(school). He/she will be transported/escorted between the child care
facility and the school by ( check applicable type): ______school bus, ______head start bus, ______ child care facility or
______ will arrive/depart unescorted with my permission. If my child is not at the designated pickup site, or does not arrive
as planned, please contact (check applicable type): ____________ parent or guardian, or ____________ the school, in order
to confirm the child's whereabouts, as well as devise a plan as needed to locate the child. My child also has permission to
(specify, ie: work with teacher after school, attend an extracurricular class or meeting, depart for home at specific time, etc):
________________________________________________________________________________________________________
Parent/Guardian Signature _________________________________________________ Date__________________________
Does your child respond well to transitions?
Emergency Consent Form
Permission for Child to be Transported to a Hospital
If your child needs emergency medical care and you are not available to give formal consent to medical
authorities, care may be unnecessarily delayed. To protect your child, please complete this EMERGENCY
CONSENT FORM. In the event of a medical emergency, this form will accompany your child to the hospital.
I hereby authorize the ART4LIFE STAFF to give consent for any and all medical and/or surgical treatment that
may be required for my child during my absence from August 2020 until June 2021.
CHILD’S FULL
NAME
DATE OF
BIRTH
ALLERGIES
CHRONIC
ILLNESSES
CURRENT
MEDICATIONS
DATE OF
LAST TETANUS
IMMUNIZATION
Physician: ________________________________________ Telephone: _______________________________
Dentist: ___________________________________________ Telephone: ______________________________
Home address of parent/guardian: ______________________________________________________________
Telephone of parent/guardian: _____________________
Employer: _____________________________________Telephone: __________________________________
Health insurance co.: _________________________ Policy holder name: ______________________________
Member #: ___________________________________________ Group #: _____________________________
Emergency contact (other than parent/guardian): __________________________________________________
Telephone: _________________________
Please list an emergency contact of someone within walking distance of your school who can pick up your child
in case of a weather emergency or natural disaster that may inhibit your ability to safely reach the school.
Name: ____________________________________________ Phone: _____________________________
Parent/Guardian signature: __________________________________ Date: ____________________________
Field Trip Permission
By signing this permission slip you give Art4Life teachers authority to take your child on field trips.
o This permission slip is for trips within walking distance of Richmond Elementary School and also field
trips on All Days.
o When taking field trips off school grounds, Art4Life uses public transportation to locations disclosed to
you prior to that day.
o Field trips can occur on short notice.
o Departure time, the number of children and estimated time of return will always be posted on the parent
board.
o Those children without signed permission slips will not be allowed to participate in field trips.
o Parents and guardians are always welcome to join Art4Life on field trips.
I have read the above information and agree that my child, ,
has my permission to participate in walking field trips and All Day field trips through the Art4Life program.
Parent or Guardian Signature Date
Art4Life School Disclaimer
I understand School District No. 1, Multnomah County, and Richmond Elementary School provide only space
for the Before and After School Arts Program, Art4Life Richmond Elementary School does not supervise the
care or provide program staffing or transportation, and I will not expect Richmond Elementary School to take
any responsibility for the care of:
Child’s Name
Including, but not limited to, mediating conflicts with provider, or the manner in which the facility is operated
even if the school staff has knowledge.
Parent or Guardian Signature Date
Basic Expectations
Please review the following expectations with your child before his or her first day with Art4Life:
o Children enrolled in the Art4Life program are expected to report to Art4Life directly following dismissal
from their regular school day.
o Children participating in additional after-school programs (chess club, girl scouts, helping a teacher in their
classroom, etc.) must submit a Permission to Attend a Contracted Class form. Students are required to
report to Art4Life before attending these activities.
o An Art4Life staff member will escort kindergartners from their classrooms to the Art4Life space.
o Art4Life is an arts program. All students are expected to participate in all activities, and to follow all rules
and schedules imposed by Art4Life and its teachers.
o Children and parents must treat the Art4Life staff, supplies and other participating children with respect and
courtesy.
I have read and explained these expectations to my child.
Parent or Guardian Signature: ____________________ Date: __________________
Art4Life Behavior Expectations
Art4Life aligns its behavioral and disciplinary polices with Portland Public Schools and each school’s
principal’s guidelines. Parents/guardians are expected to take an active role in Art4Life’s efforts to implement
positive behavior supports and to work with schools to address their student’s behavior.
Positive Behavior Interventions and Supports
Art4Life participates in district-wide trainings for Positive Behaviors Interventions and Supports. Our staff
supports the children in learning responsibility and respect for themselves and others. Our role is to help
children learn to cooperate with one another, to practice self-control, and to develop problem-solving skills. If
problems arise, we follow this three-tiered course of action:
o When a child requires redirection, a member of the staff will restate the agreed-upon expectations.
o If redirection is needed a second time for the same behavior, a teacher will discuss how the group is
being affected and work to create astrategyfor success. This reflection may be written or a verbal
discussion and will be communicated with the child’s parents at the end of the day.
o If redirection is still needed for a third time, the staff of Art4Life will meet with the parent and work
with the school’s principal, the child’s school teacher and any other school support staff to help the child
return to a respectful and positive space at Art4Life.
For more information regarding the above, please refer to the online comprehensive parent handbook or
the parent board. Continued enrollment in the Art4Life program is at the sole discretion of Art4Life.
Notwithstanding the Behavior Contract referenced in the Enrollment Packet, any behavior by the parent(s) or
the student that is detrimental to the Art4Life program or its employees may result in immediate expulsion from
the Art4Life program.
Portland Public Schools (“District”) and Before- and After-School Childcare Providers (“Program”) can
effectively support your student when the school and Program are allowed by you to share important
information about your child for the purposes of student support, program planning, staffing, and safety.
For the 2020-2021 school year, the District is requiring every parent/guardian with a student enrolled in a
Program to sign this release form. By signing this release form, you allow your child’s school to share
information about your student with the Program. This release form also grants permission to the Program to
share information about your student with the school on a need-to-know basis.
This authorization expires: September 30, 2021 (not more than one school year).
_____________________________________________________________________________________
Student’s/Child’s Name Attending School Date of Birth
______________________________________________________________________________________
Name of Program Location of Program
By signing this release, I understand that:

Providing this consent is a requirement for my child to participate in the Program.
This consent allows verbal information about my student’s behavior, safety, education, health, social
skills, and accommodations to be shared between the Program and school.
_____ (requires parent/guardian initials
) In addition, I specifically authorize the release of school
records as needed. Records will only be shared on an “as needed” basis.
The Program will keep all information about students confidential according to its own policies.
I consent to the use and disclosure of the above information and/or records.

_____________________________________________________________________________________
Signature of Parent or Legal Guardian Relationship Date
Contract 2020-21 School Year
Does your child have an Individual Education Plan? ☐ YES ☐ NO
If yes, please share any information regarding this plan that may help our staff provide a supportive and
consistent environment before and after school.
_________________________________________________________________________________________
_________________________________________________________________________________________
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2020-2021 ENROLLMENT PACKET Before and After School Program

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Completed 16 March 2021

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