RTH Summer Enrichment Program 2014 2013

RTH Summer Enrichment
Program 2014
2013-2014 Application Packet
Please return this completed application packet to 835 Huntington Ave
(Rear). WITH THE FOLLOWING ITEMS:
ONE MONTH’S PROOF OF INCOME (copies of consecutive pay stubs)
RTH TUITION AGREEMENT (non-voucher families) or A COPY OF
YOUR VOUCHER (voucher families)
SEPTEMBER’S TUITION IN CHECK OR MONEY ORDER
To hold your slot(s) in the program, your application and deposit fee of $80.00
and full tuition must be returned to the RTH Office as soon as possible or no
later than Friday, June 20th, at the 6pm mandatory parent meeting. If we
have not received your application or tuition by this date, your slot(s) will be
forfeited and given to a child on the waitlist.
Questions? Contact Stephanie Ellis, Summer Enrichment Program Director
617-232-9222 or [email protected]
The Commonwealth of Massachusetts
Department of Early Education and Care
Roxbury Tenants of Harvard Summer Enrichment Program
Child Enrollment Form, 2014
Child’s Information
Child’s Name:________________________________________________ Date of Birth:_____________________
Age at Admission:____________________________________________ Today’s Date:__________________ ___
Child’s Home Address:_________________________________________________________________________
Home Phone Number:_________________________________________________________________________
Primary Language:_______________
___________________ _______ Sex:_____________________
Current School:__________________________________________________________________
Current Grade Level:________________________
School Phone Number:___________
School Address:
____________
I certify that documentation of physical examination and immunizations in accordance with public school health
requirements and lead poisoning screening in accordance with public health requirements are on file at my
child’s school. Parent/Guardian initials:
Parent/Guardian Information
Parent/Guardian Name: ____________________________
Relationship to Child:_______________________________
Home Address:____________________________________
Reachable Phone Number:__________________________
Alternate Phone Number:___________________________
Email Address:____________________________________
Parent/Guardian Name: ____________________________
Relationship to Child:_______________________________
Home Address:____________________________________
Reachable Phone Number:__________________________
Alternate Phone Number:___________________________
Email Address:____________________________________
Business Name:___________________________________
Business Address:_________________________________
Business Phone Number:___________________________
Hours at Work:________________________
Business Name:___________________________________
Business Address:_________________________________
Business Phone Number:___________________________
Hours at Work:________________________
Additional Information
Child’s Physician:_____________________________________________________________________________
Address:______________________________________________________ Phone Number:_________________
Allergies/Special Diets?_________________________________________________________________________
Individual Health Plan for child with a chronic health condition? If yes, please attach._______________________
Copies of any custody agreements, court orders, and restraining orders pertaining to the child? If yes, please
attach.____________________________________________________________________________________
Special limitations or concerns? ________________________________________________________________
X_______________________________________________
Parent/Guardian Signature
_________________________
Date
The Commonwealth of Massachusetts
Department of Early Education and Care
Roxbury Tenants of Harvard Summer Enrichment Program
Transportation Plan and Authorization, 2014
CHILD’S NAME:________________________________
_____
MY CHILD WILL ARRIVE AT THE PROGRAM (please check one):
___Parent drop-off (Arrival time:
)
___Unsupervised walk to program from home or other bus stop (Arrival time:
)
OTHER (please specify
)
MY CHILD WILL DEPART FROM THE PROGRAM (please check all that apply):
___Parent Pick-up
___Unsupervised Walk (Your child must be 7 or older to walk home unsupervised).
___Other Authorized Pick-up (Please list the names of ALL adults authorized to pick-up your child):
Transportation Agreement
I understand that it is my responsibility to call the RTH if my child is unable to attend the program due to
illness or other circumstances on any given day. I have read the Late Fee Policy in the Parent Handbook, and
understand I will be charged $10 for the first 5-15 minutes I am late past 6pm, and $10 for each additional 15
minute period thereafter.
Parent/Guardian Signature:_____________________________
_Date___________
RTH Summer Enrichment Program
2014 Health Information Form
My child has problems with heat or exposure to the sun.
If yes, please explain:
YES
NO
My child has allergic reactions to insect bites and/or stings.
If yes, please explain:
YES
NO
My child has allergic reactions to certain environments.
If yes, please explain:
YES
NO
My child needs daily medication during program hours.
If yes, please explain:
YES
NO
My child wears corrective eyeglasses.
If yes, please explain:
YES
NO
My child has the following physical disabilities:
My child has the following developmental disabilities:
My child has the following learning disabilities:
Any specific behavior issues or needs? Please provide any information relevant to supporting your child
during the ASP:
Parent/Guardian Signature
Date
RTH Summer Enrichment Program 2014
Photo and Video Release Form
By signing below, I give my consent for my child,
, to
be photographed and/or videotaped by Roxbury Tenants of Harvard, for the purpose of
program projects and/or organization publicity.
Parent or Guardian Signature
Date
Check here if you DO NOT want photos of your child used for organization
publicity or program projects.
RTH Summer Enrichment Program, 2014
Acknowledgement of Summer Enrichment Program Behavior Expectations and
Discipline Guidelines
I have read the behavior expectations and discipline guidelines in the 2014 SEP Parent
Handbook. I understand the program rules, expectations, and policies for consequences, suspensions,
and terminations. I will review the rules with my child prior to the beginning of the ASP to make sure
they understand the basic program expectations. I understand that the RTH staff and program director
will also review the behavior expectations and consequences with children upon their enrollment in
the ASP.
Parent/Guardian Signature:
Date:
RTH Summer Enrichment Program, 2014
Tuition Agreement Non-Voucher Families (RTH Residents)
One Per Household
STEP ONE: Fill out the information below.
Parent Name/Head of Household:
Number of people in household:
Current Monthly Household Income:
STEP TWO: See the attached RTH Tuition Sliding Fee Scale for RTH Residents. Find your daily tuition rate based
on your household size and household income. Fill out the box below based on your information:
Child’s Name:
Daily tuition rate (see attached chart):
Siblings receive a 50% discount off the first child’s tuition. Please write the names of
additional children from your household enrolled in the RTH Summer Enrichment Program
this year:
STEP THREE: Attach copies of one month’s proof of income (4 consecutive weekly pay stubs, 2 consecutive
biweekly paystubs, copy of any welfare income, etc.) to this application.
2014 Tuition Agreement:
I agree to pay the above daily fee for my child’s participation in the RTH Summer Enrichment program.
For my child’s participation in the program, I understand that advance monthly payments are due by the
twentieth of each month prior to the month of service. I understand that my monthly tuition will be equal to my
daily rate multiplied by the number of billable days in a month, and that it is my responsibility to ensure my
payments are made on time. I understand that billable days in a month include all weekdays in a month during
the SEP operating year (July 7th-August 22nd 2014), including holidays, emergency closures, or days my child is
absent due to illness or vacation. I understand that no refunds are given for these weekday closures or absences.
PARENT/GUARDIAN SIGNATURE:
DATE:

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