SUMMER EXTRAS 2012 REGISTRATION FORM by r59iLjIi

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									                                   SUMMER EXTRAS 2012 REGISTRATION FORM

      PLEASE COMPLETE AND RETURN THIS FORM WITH YOUR CHOICE OF SCHEDULE AND TUITION

The Park Ridge School District EXTRAS program will operate in the Summer of 2012 for 9 weeks for grades K-6 at East
Brook Elementary School from June 25 to July 20, and at West Ridge Elementary School from July 23 to August 24. The
Program is open to the children of Park Ridge Public Schools and is not intended to compete with the Borough
Summer/Day Camp.

Summer EXTRAS Program operates between the hours of 8:00 a.m. – 6:00 p.m. daily, Monday through Friday. Please
select the program session and tuition that best fits your needs.

                                    PLACE AN ‘X’ NEXT TO DESIRED SCHEDULE

Full Program
9 weeks 8am-6pm daily, MF                $1285.00                                 __________

Full AM only
9 weeks 8am-1pm daily, MF                $677.00                                  __________

Full PM only
9 weeks 1pm-6pm daily, MF                $677.00                                  __________

Half Program
6/25-7/27 or 7/23-8/24
5 weeks 8am-6pm daily, MF                $785.00                                  __________

Half program AM only
6/25-7/27 or 7/23-8/24
5 weeks 8am-1pm daily, MF                $479.00                                  __________

Half program PM only
6/25-7/27 or 7/23-8/24
5 weeks 1pm-6pm daily, MF                $479.00                                  __________

One Week
5 days 8am-6pm daily, MF                 $220.00                                  __________

One Week AM or PM only
5 days half day daily, MF                $130.00                                  __________

Daily Rate- Half Day                     $27.00
                                                                                  __________

Daily Rate- Full Day                     $52.00
                                                                                  __________

One time Family Registration fee         $35.00
                                                                                  __________




                                   Total Amount Enclosed             $____________

To register for the Park Ridge Summer EXTRAS Program, please complete and return the registration form along with the
payment. Check should be made payable to the Park Ridge Summer EXTRAS. Tuition and Registration are due in full no
later than June 1, 2012.

              Child’s Name__________________________________________________________

              Parent’s Name________________________________________________________

              Address______________________________________________________________

              Home Phone #______________________ Bus. Phone #_______________________
                                       Park Ridge Board Of Education
                                      Summer Extras Registration Form


       Child’s Name                Grade            Teacher                School          Date of Birth           Allergies




                                                 Mother                                               Father
Name
Home Address

Home Phone #

Cell Phone #

Work Phone #
Employer’s Name



 In case of emergency (illness, alternate pick-up, late pick-up) the following people have permission to pick up my child:

                                        Contact #1                        Contact #2                        Contact #3

Name

Relationship

Home Phone #

Work Phone #

Cell Phone #

Address
                                        CONSENT AND RELEASE


I (We) _____________________________________________________________
Residing at _________________________________________________________
in Park Ridge, New Jersey, in consideration of the benefits to our child(ren)
__________________ participating in the Park Ridge EXTRAS Programs, do
hereby release the Park Ridge Board of Education from any and all claims or
actions whatsoever based on the participation of my child in any and all activities
including but not limited to any injuries which may be sustained from any use of
toys, from other children, or from the premises where the program functions occur.

This Consent and Release shall be deemed to be continuous unless specifically
revoked in writing.




___________________________________________________________________________   _______________________________________

(Parent/Caregiver Signature)                                                  (Date)

								
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