LEAP Registration Form 2023-2024

Child #1 First Name *

Child #1 Last Name *

Child #1 Grade *

Do you have additional children? *

Child #2 First Name *

Child #2 Last Name *

Child #2 Grade *

Do you have additional children? *

Child #3 First Name *

Child #3 Last Name *

Child #3 Grade *

Phone Number *

Street Address *

Who does the child live with? *

Email Address *

Mother's Full Name *

Work Phone *

Cell Phone *

Father's Full Name *

Work Phone *

Cell Phone *

Medical Information

Allergies

Regular Medications

Other Information

Doctor's Name *

Phone Number *

In the event of an emergency, the LEAP staff has my permission to take my child to the nearest medical facility. *

Emergency Contacts & Persons Permitted to pick up my child (Other than Parents!)

Emergency Contact #1 *

Emergency Contact #1 Phone *

Emergency Contact #2 *

Emergency Contact #2 Phone Number *

Emergency Contact #3 *

Emergency Contact #3 Phone Number *

Registration/Activity Fees

We have limited spots available in each grade level, so it is important to register by Wednesday, July 26. Students accepted into the program will be notified by Friday, July 28.

Registration Fees and Dues

Registration Fee - $30.00 per family
Monthly Tuition - $200 a month (Due by the first Monday of each month). This covers a 180 school day calendar which comes to approximately $11.17 a day.
Late Fee - $15.00 (Will be charged after two school/business days). Students will be subject to dismissal from the program if an account is one month delinquent.
Drop in Rate - $15.00 per visit. Will be invoiced for 5 visits @ $75.00. Money will be deducted from the account when they stay.

Late pick up is charged at $1.00 per minute beginning at 6:01 pm for ALL plans.

I will be paying: *

I intend on my child attending: *

I acknowledge that I have read and understand the LEAP Operating Procedures and I understand the guidelines of this program. I understand that all fees are due as stated above and that my account must be kept current. I understand that no student with a balance in any amount will be permitted to attend LEAP, field trips, or other extra-curricular activities until the balance is being paid in full. I further understand that fees paid in advance will only be refunded in extenuating circumstances, including, but not limited to job/military transfer. *

Parent Signature *

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