Fillable Child Care Options & Rates Afternoon Care: End (Kama'aina Kids)

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Child Care Options & Rates Afternoon Care: End (Kama'aina Kids)

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  • 12 check-boxes
  • 82 other fields

Country of origin: US
File type: PDF

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Gender
D.O.B
Grade
Room#
Gender
D.O.B
Grade
Room#
3
8
*Please return all copies to our Main Office
I hereby authorize Kama‘aina Kids and its employees to exercise these discipline policies in regard to my child.
Signature of Releasor Date
SPONSOR
I hereby agree that, if Kama‘aina Kids staff is unable to contact me or one of the persons listed as emergency contact, I hereby consent that if my child exhibits signs of illness or injur, that at the discretion of the Kama‘aina Kids supervisor on duty, my child
may be taken to the nearest medical facility and be given any examination or treatment that is deemed necessary by the personnel of the medical facility and, if permissible by medical facility, subse-quently released to Kama‘aina Kids Supervisor or staff-in-
charge.
I hereby authorize Kama‘aina Kids to use my child’s name and video or photograph at any time and in any manner in connection with its advertising, publicity, and public relations programs. The video-photo may only be used by Kama‘aina Kids. No further
claims will be made by me.
I hereby give my child permission to attend and participate in the activities conducted by Kama‘aina Kids’ program. These activities include aquatics, off-property excursions, van transportation, and enrichment activities.
DISCIPLINE
Discipline is used to assure the safety and well being of all program participants. All children are expected to respect themselves, other people and their property. If a child is not following the guidelines of Kama‘aina Kids staff consistent with these
expectations, then the child will take a time out from the activity at the staff memb’s discretion. A child with consistent behavior problems will be sent to Kama‘aina Kids’ Program Site Coordinator who may contact the parents for the purpose of removing
the child from the program. Kama‘aina Kids reserves the right to refuse any child’s future participation in its programs.
Name HDL # Work Cell
Authorized Pick-Up & Emergency People (Other than parent / legal guardians):
∙ $5 Late Pick-Up Fee ∙
$15 Late Payment Fee
7 Medical Insurance Policy #
Kama‘aina Kids is an equal opportunity organization and does
not deny enrollment or discriminate on the grounds of race,
color, religion, sex, or national origin. Eligibility to participate in
this program is reliant upon verification of a child’s ability to
function safely in a 1:15 ratio.
Name HDL # Work Cell
Doctor Address City
6 Doctors Name Phone
State Zip
5 Medical Conditions/Allergies Child 1: Child 2:
4 Mailing Address City State Zip
Parents Name Email Address HDL # Work Phone Cell Phone
Parents Name Email Address HDL # Work Phone Cell Phone
Parents / Legal Guardians (AUTHORIZED TO PICK UP CHILD)
Last Name First Name
*Daily rate (8 days or less only)
Last Name First Name
*Daily rate (8 days or less only)
2021-2022 St. Elizabeth After School Program
Afternoon Care: End of School-5:30 pm
Child Care Options & Rates
Please check applicable boxes & fill out blank spaces.
Registration Form
Questions? Call 808-479-3158 or 808-262-4538
Daily*
Monthly
$10
$160
1 Child:
2 Child:
2021-2022 Automatic Tuition Payments (ATP) Authorization Form
We are excited to offer the safety, convenience and ease of Tuition Express® – a
payment processing system that allows secure, on-time tuition and fee payments to
be made from either your bank account or credit card.
Payments will be processed beginning with the first business day of each month.
An email address is required to access receipts online.
Credit union members: please contact your credit union to verify account and routing numbers for automatic payments.
Payee Info
Payer Last Name
Payer First Name
Phone
(required)
Email Address
(required)
Child Last Name
Child First Name
Monthly Tuition
Morning Care
After Care
Total
1.
$ $ $
2.
$ $ $
3.
$ $ $
ATP Start Month
School Name
Total Monthly Tuition
$
Payment Option A (Credit Card)
Visa
Mastercard
American Express
Discover
Cardholder Name
Credit Card Number
Exp. Date
CVV#
Billing Address
City
State
Zip
Payment Option B (Bank Account)
Checking
Savings
Bank or Credit Union Name
Bank or Credit Union Address
Routing Transit Number (see sample below)
Account Number (see sample below)
Please note that in addition to the monthly tuition charge, the following fees shall be assessed:
There shall be a $20 one-time processing fee assessed per family for each school year.
There shall be a $30 service charge assessed for any returned checks.
I hereby authorize Kama`āina Kids to initiate credit card charges to the above-referenced credit card account (Payment Option A) OR,
initiate debit entries to my checking or savings account, indicated above (Payment Option B). I am required to give 10 days written
notice to cancel this authorization.
Donation
Kama`āina Kids is a not-for-profit organization. Should you wish to make a tax-
deductible donation to assist our financial aid and scholarship program, please indicate
your donation frequency and amount here:
Frequency:
One-time
Monthly
Donation
$
Print Name
Authorized Signature
Date
St. Elizabeth
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Child Care Options & Rates Afternoon Care: End (Kama'aina Kids)

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Completed 30 June 2021

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