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Option_2-Punch_Card_Fall_2011_8_to_9_Program_Enrollment_Application-Final

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     Fran Konieczko; Chair  Lori Ackatz; Vice Chair  Michael Gerhardt; Treasurer  Elizabeth Bielke Secretary 

                             A.N. Pritzker Elementary School PTO ‘8 to 9’ Program Enrollment Application
                                                 Option 2: Pilot Punch Card Fall 2011
    Thank you for your interest in the A.N. Pritzker Elementary before-school program, sponsored by the A.N. Pritzker PTO and officially known as the 8 to 9
    Program.

Program Overview:
    Goals:
           To bridge the time gap for parents who otherwise would not be able to send their child to a late start school.
           To provide an environment that is safe for Pritzker students, supports Pritzker parents, is within CPS guidelines, and is
            able to be effectively administered.
           To charge fees which are competitive and affordable as well as to cover the teacher salaries and operational costs.
    Hours of Operation:
           The 8 to 9 Program Fall 2011 term will begin on September 6, 2011 and end December 23, 2011. There are 70 student
            attendance days for the fall 2011 term.
           The 8 to 9 Program provides 1 hour of supervised care from 8am-9am Monday-Friday on regularly scheduled school
            days. The 8 to 9 Program will not operate on holidays, professional/staff development, or any day that the school is
            closed to students.
           The 8 to 9 program will be held in the cafeteria and at least 2 teachers will supervise students.
    Eligibility for Enrollment:
           The 8 to 9 Program will not exceed state mandated student-teacher ratios and will have sufficient enrollment to support
            all incurred expenses (i.e. teacher salaries, insurance, administrative costs etc).
           Student(s) must be enrolled in grades K-8 and attend A.N. Pritzker Elementary School.
           8 to 9 Program Enrollment is limited to 56 students. This includes students enrolled in both Option 1 & Option 2.
           A completed enrollment application for each student must be on file in order to purchase a punch card.
    Cost:
           Fees for the Fall 2011 Term: Non-refundable $10.00 Application Fee. The daily Punch Card fee is $5.00 per day. Once the
            completed application and application fee is received by the PTO, parents may purchase either a 10-day ($50.00) card
            and/or 20-day ($100.00) use cards.
           Fees for the 8 to 9 Program can be paid in the following ways:
                Via Pay Pal. The email you receive confirming enrollment will include instructions on how to pay via Pay Pal
                    directly from your checking account or with a credit card. You do not need a Pay Pal account to use Pay Pal.
                Cash or Money order payable to Pritzker PTO at student orientation on September 2, 2011
                School is closed until September 1, 2011. Parents cannot drop off applications or payments at school. Mail your
                    completed application and payment of fees to the A.N. Pritzker PTO, ATTN: 8 to 9 Program 1435 W. Blackhawk
                    St., Chicago, IL 60642
           Your Pay Pal receipt OR money order receipt will serve as your receipt. You will receive a statement at the end of each
            semester via email from PritzkerPTO@yahoo.com.
Program Rules:
    Attendance
           Parents may enter the building at 8:00am, per Pritzker school policy. If you arrive prior to 8:00am, you will need to wait
            outside until you are allowed to enter the building by Pritzker administration or staff.
           Parents must escort the student(s) to the cafeteria and sign the student in each day.
           Program staff will keep punch cards affixed to the sign in clipboard. Program staff will track student attendance days. 8
            to 9 Program staff will inform parents of the need to renew punch card(s). Parents may purchase new punch cards from
            program staff.
           Students must remain inside the cafeteria and under the supervision of their assigned teacher until 9am.
           Students must have an Extra Curricular Information Form on file regardless of participation status (page 4).
           Students in the 8 to 9 Program must have an Extra Curricular Information Form on file in order to be released from the
            cafeteria if they participate in an A.N. Pritzker before-school activity (i.e. Violin, Cheerleading, Sports, Band, etc).

    Behavior
         At 8:40am, all activities will stop. Prior to leaving the cafeteria students should return all supplies, games, activities, etc
          to the designated storage area and all waste should be thrown away. Failure to return the cafeteria in the condition in
          which it was found at 8am puts the 8 t o9 Program continuation in jeopardy.
                                     A.N. Pritzker Elementary School PTO                                                   Page 2
                           ‘8 to 9’ Program Enrollment Application – Option 2: Pilot Punch Card Fall 20118

         The student must abide by all A.N. Pritzker Elementary School rules and regulations.
         There is absolutely NO fighting, bullying, abusive language, or disrespect of any kind tolerated from students or parents.
         No food or drink will be provided, nor will it be allowed in the cafeteria; all food and drink brought to school by students
          should remain contained in the student’s backpack until the student is dismissed from the program.
         Video games, cell phones, or other non-educational items may not be brought out during the program. All items of this
          nature brought to school by students should remain contained in the student’s backpack for the entire time the student
          is participating in the program. If the student removes the item from their backpack, the item will be confiscated by the
          teacher. Once confiscated, the item may be returned only to a parent/guardian.
    Consequences
         Failure to adhere to financial obligations or program rules will result in the student being removed from the 8 to 9
          Program.
                                                                                                                        rd
         The Pritzker Demerit/Reward System will not be used during the program as it only applies to students in 3 grade or above.
Parent Responsibilities:
         Read and agree to abide by the rules of the program and financial responsibilities.
         Accompany your child into the cafeteria AND sign your child into the program each attendance day.
         Students cannot attend the program without a completed application and valid punch card. One student allowed per
          punch card. When necessary, program staff will verbally notify parents when to renew punch cards.
         Renew punch cards in a timely manner. Students will not be permitted in the 8 to 9 Program without a valid punch card.
          If parents do not renew the punch card, students will be sent to the Main Office.
         Submit application fee and a completed application for each student you wish to enroll.
         You can submit your completed application beginning July 25th in one of the following ways:
              Print, complete, and sign the Enrollment Application. Scan pages 3 & 4 of the document, making sure that you
                  have signed page 3 and email your application PritzkerPTO@yahoo.com.
              Drop off your completed application & payment to the PTO at Student Orientation on September 2, 2011.
              Mail your completed application & payment of fees to the A.N. Pritzker PTO 8 to 9 Program
                 1435 W. Blackhawk St. Chicago, IL 60642
         Only completed applications that include the $10 application fee will be considered.
         Confirmation of student enrollment will be sent via email.
         NO REFUNDS WILL BE ISSUED FOR UNUSED DAYS ON ANY PUNCH CARD.
Payment Options:
    Fee Schedule:
         Fees for the Fall 2011 Term: $10 application fee & appropriate punch card fee. The 10-day Card will be $50.00 and the
          20-day card will be $100.00
      Total payment for the initial punch card must be received by September 6, 2011.
         Fees are equivalent to $5perday. Please purchase the card you feel best meets your needs. Remember that NO
          REFUNDS WILL BE ISSUED FOR UNUSED DAYS ON ANY PUNCH CARD.

    The 8 to 9 Program, with your help, has been a success. The PTO and the 8 to 9 Program staff take this opportunity very
    seriously. It is the hope of the PTO that this program will continue to provide our students with a safe environment and
    support our parents who would otherwise not be able to send their children to a late start school. The Pilot Punch Card
    program will be evaluated during the Fall Term. If the pilot punch card program enables enrollment to increase and PTO is able
    to meet the staff payroll, the program will continue for the Winter 2012 Term. We thank you for your participation!

    Don’t cause a delay in your Enrollment Application processing! Include the following when you turn in your application:
             Complete, sign and return pages 3 & 4 of the 8 to 9 Program Enrollment Application
                     AND the $10.00 application fee for each student enrolling in the program.
             For each enrolling student the punch card fee of either $50.00 ( 10-Day Punch Card) or $100 (20-day Punch
                 Card)
             Additional Emergency Contacts, if necessary.

    If you have questions or concerns about the A.N. Pritzker 8 to 9 Program, please email PritzkerPTO@yahoo.com or you may
    directly contact:
    Francine Konieczko, PTO Chair               (773) 384-2116                      fkonieczko@sbcglobal.net
    Lori Ackatz, PTO Vice Chair                 (773) 615-3291                      lackatz@earthlink.net
    Mariana Ziolkowski; 8 to 9 Register         (773) 534-4415                      MEZiolkowski@cps.edu
                                                          A.N. Pritzker Elementary School PTO                                                                          Page 3
                                                                 Option 2: Pilot Punch Card Fall 2011
                                                                        Student Information:

  Student’s Name:                                                                                                            Gender:               Male              Female
                                                 first           middle initial              last


  Date of Birth:                                                                  Grade:                 Room:                           Teacher:
                                Month               Day   Year


  Address:
                     #                  Street                                               Apt #                    City                           State       Zip


  Does the student have any special needs, allergies, chronic conditions, problems getting along with other students etc?



Contact Information:
    Primary Parent or Guardian Enrolling the Student:

  Name:                                                                                                       Relationship to Student:


  Address:
                     #                  Street                                               Apt #                    City                           State       Zip


  Home Phone:                                                                               Cell Phone:


  Work Phone:                                                                                        Email:

    Emergency Contact #2:

  Name:                                                                                                       Relationship to Student:


  Address:
                     #                  Street                                               Apt #                    City                           State       Zip


  Home Phone:                                                                               Cell Phone:


  Work Phone:                                                                                        Email:

    Student’s Physician Information:

  Name of Physician:                                                                                                         Office Phone:


  Address:
                     #                  Street                                                                        City                           State       Zip


  Insurance Company:                                                                                            Policy #:

    By signing this Enrollment Application, my child and I agree to abide by the rules and regulations set forth in pages 1, 2 & 4.

    In the event of a medical emergency, I hereby authorize and give consent to the PTO and its employees/volunteers to secure only necessary treatment for my
    child (ren)’s immediate care from any accredited hospital, clinic and/or physician. I agree that I am responsible for any and all expenses incurred for such
    emergency medical care and treatment.

    I fully assume responsibility for injuries my child may receive and for articles lost or stolen while participating in the 8 to 9 program; and I hereby release the
    PTO and its employees/volunteers from liability for any injury sustained by the student.

    Accepted and Agreed:

                                                          Date:                                                                                     Date:
  Parent / Guardian Signature                                                              Student Signature
                                                        A.N. Pritzker Elementary School PTO                                                         Page 4
                                             ‘8 to 9’ Program Enrollment Application – FALL 2011
    Please complete a form whether or not your child participates in extra-curricular school activities.
Extra Curricular Activity Information:
    My child participates in the following before-school program(s):

    You do not have to list activities/dates/times for activities in which your child participates unless they will be first coming to the 8 to 9
    Program and then leaving in order to participate in another A.N. Pritzker School before-school activity.

    If already signed in and a student leaves the cafeteria at the time designated below, they are no longer the responsibility of the 8 to 9
    Program.

                                                                                                                      Is NOT participating in a Pritzker
  Student’s Name:                                                                                                  extra-curricular activity before school
                                          first                middle initial                 last


    Activity #1:

  Activity:                                                                          Teacher / Sponsor:


  Day activity takes place:                                                             Location / room:


   Activity time (student will be released from the program 5 minutes prior to start time):


    Activity #2:

  Activity:                                                                          Teacher / Sponsor:


  Day activity takes place:                                                             Location / room:


   Activity time (student will be released from the program 5 minutes prior to start time):


    Activity #3:

  Activity:                                                                          Teacher / Sponsor:


  Day activity takes place:                                                             Location / room:


   Activity time (student will be released from the program 5 minutes prior to start time):


    Activity #4:

  Activity:                                                                          Teacher / Sponsor:


  Day activity takes place:                                                             Location / room:


   Activity time (student will be released from the program 5 minutes prior to start time):


    Activity #5:

  Activity:                                                                          Teacher / Sponsor:


  Day activity takes place:                                                             Location / room:


   Activity time (student will be released from the program 5 minutes prior to start time):

				
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