FeePaymentAgreementForm

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					                        [School Name] Afterschool Program
                           Fee Payment Agreement Form


Afterschool payments must be paid monthly by the third school day of the month. Services will
be suspended if fees are not received in a timely fashion.

Adjustments are not made for absences as fees are calculated on a monthly basis. Each child has
a reserved place in the program and fees must be paid to maintain the child’s place in the
program whether the child is present or not.

This Fee Payment Agreement is a temporary measure in an effort to meet an emergency need
and should not be construed as a regular payment arrangement. The Fee Payment Agreement
may not exceed a three month period. After three months the Fee Payment Agreement will be
revisited to reevaluate the need.

If this agreement is not met, services will be suspended immediately. Your child(ren) may not
return to the program until the account is brought current.

Parent Name:

Child(ren):

Start Date of Plan:                                End Date of Plan:

Amount Due: $

Payment Arrangement:




Parent Signature                                                  Date



Principal Signature                                               Date



Afterschool Director Signature                                           Date




Revised 10/3/2008

				
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