Adventure Club Enrollment Form 2021

TO AVOID DELAY IN ENROLLMENT, PLEASE COMPLETE THIS FORM IN IT'S ENTIRETY!

Referral Source:*

If a currently enrolled family referred you to our program, and you have never been enrolled in our program before, please share with us the First & Last name of the parent referral. They will receive a $25 in-house credit as long as they're actively enrolled.

(Please type "N/A" if this does not apply)

Childcare Payment Assistance ~ Please choose one of the following:*

I DO NOT receive state subsidy assistance, foster care, or Swift Start assistance.
I am currently approved and receiving subsidy childcare assistance.
I have applied for subsidy assistance and I am currently on the wait list. STOP! You will be responsible for ALL fees and tuition until approved.
My child is part of the foster care system.
I am currently approved through Swift Start.

Which county are you receiving assistance from:*

Montgomery County
Floyd County
Giles County
Pulaski County
Radford City
Other - county is not listed above

Other county you are receiving assistance from:*

New DSS Subsidy Policy -- Effective July 10, 2019*

Child care subsidy that is paid through the Department of Social Services must meet the following requirements to be actively enrolled at The Adventure Club:

1. Parents/Legal Guardian must swipe their card each morning and afternoon.

2. A Child will not be able to attend the program unless the DSS card is swiped.

3. Parents must swipe BEFORE checking into Procare (our accounting/attendance system) or signing in children.

4. If a parent forgets the DSS card, a child will not be allowed to attend until the card is swiped. (Taking a photo of your card for manual entry is a good way to have back up if your card is lost)

5. If a parent has a co-fee, those fees are collected in advance before services are rendered. A credit card or checking account is required for automatic debit.

6. If a child is absent, the back swipe must be done the following day the child returns. Any unapproved absences will be the responsibility of the parent to pay.

Acknowledgement: I have read and will abide by the policies listed above.

Child Information & Consents:

How many children are you enrolling?*

Tuition Types & Packages Explained:

Enrollment for: "BEFORE CARE, AFTER CARE, BEFORE & AFTER CARE, & BUNDLED PACKAGE OPTIONS THAT INCLUDE WEDNESDAY FULL DAY CARE":
* Available for children needing care before and/or after school, and bundled package options including Wednesday full day care paying a flat weekly rate.

Enrollment for: “FULL DAY ONLY Child Care on NON-SCHOOL DAYS”:

INCLEMENT WEATHER & HOLIDAY'S ONLY: If you only need care for your child K-12 yrs on (Inclement Weather & Holiday's), you may enroll at Galaxy Play Only at a daily rate of $50 per child, each day.

ADD-ON FEES: If your child is enrolled for Before and/or After, or Bundled care at one of our school sites, they will attend Galaxy Play on all (Inclement Weather/Holiday's) at the add-on rate of $21 per child, each day. **Apart from AES students who will attend full days at the Auburn High School

WEDNESDAY FULL DAY CARE: If your child is enrolled for Wednesday's Only, they will attend Galaxy Play at the full day rate of $42 per child. Bundle options are available to add Wednesday at a discounted rate to before and/or after weekly packages. **AES will attend full days at the Auburn High School**

We provide breakfast, afternoon snack (parents need to pack a lunch), STEM activities, Lego's, board games, arts & craft, large indoor area for physical activity and team games, and outdoor playground.
1. Children will be grouped according to grade level with assigned experienced teachers.

2. Children will experience 45-minutes of learning times followed by 20-minute break. Snack and lunch times will be 30 minutes each and they will be eating in their assigned learning station.

Enrollment for: “Pre-Paid Flexible Care – FLEX CARE”:
DISCLOSURE: During Corona recovery, families who have historically used Adventure Club’s Flex Hourly Care option may wish to consider our weekly or daily package options for the fall session.

If families have unused flex hours or would like to purchase hours, please know that option remains available at the regular package rates. Our goal is to offer a wide range of pricing options that is affordable during this season of change and governmental restrictions that reduce our group sizes. Our Governor has mandated smaller group sizes in shared spaces which has changed how flex care will operate moving forward.

*The new process includes giving notice before children can use the flex option.*

Parents will need to schedule children’s attendance 24 hours in advance to ensure space is available.

If proper notice is not given, regretfully we cannot guarantee space for care that day or accommodate as quickly as we have done in the past.

If parents would like to ensure a space for their child is available on a consistent basis, we strongly encourage a switch to non-flex option.

Changes in your child’s enrollment status can be done at tac@the-adventureclub.com.

After changing the fee option, parents will be notified when the process is completed.

If parents have unused flex hours – they will be converted into a credit that will be applied to future tuition billing.

If you plan to remain with the Flex Care option you may purchase pre-paid Flex Hours in increments of: 20 hrs @ $160, 40 hrs @ $288, or 80 hrs @ $518.40.

*Special Rates Apply to Hillsville site location. -- See Hillsville Rate Sheet for information*

Flex hrs are Non-Refundable. Unused hrs will carry over to next school year.
You may also utilize our Galaxy Play location for non-school days using your available hours.

Enrollment for: “Pre-Paid Flexible Care – FLEX AUTO”:
We also offer Flex Auto (Flex hours at 10% off regular rates)! If you select this option, we will automatically re-charge your hours for you when flex time gets down to 5 hours (in 20 hour increments at a time unless told to do more via e-mail to tac@the-adventureclub.com). At the 5 hour mark, a text message and email are sent to alert you that a charge is going to be processed within 24 hours.
Flex hrs are Non-Refundable. Unused hrs will carry over to next school year.
* You may also utilize our Galaxy Play location for non-school days using your available hours.

Program Start Date?*

MM slash DD slash YYYY

1st Child:*
1st Child:

Gender First "Nickname" Last

Date of Birth:*

Which Program Site will your 1st child attend?*

Auburn Elementary School

Christiansburg Primary School

Christiansburg Elementary @ Galaxy Play for all care -- MCPS bus will transport children to and from school

Falling Branch Elementary School

Kipps Elementary School

TAC at Galaxy Play (Not enrolled @ a site) - Full Days Only @ $50 per day/child

What will be your 1st child's attendance status:*

Before Care (AM) Only

After Care (PM) Only

Before & After Care (AM & PM)

Wednesday Care Only (Full Day Rate)

Bundled Package: Before, After, & Wednesday's

Bundled Package: Before Care & Wednesday's

Bundled Package: After Care & Wednesday's

FLEX CARE ONLY: (DISCLOSURE: Spaces are based on availability -- Call office 540-382-3783 within 24 hrs of attendance)

FLEX AUTO: (DISCLOSURE: Spaces are based on availability -- Call office 540-382-3783 within 24 hrs of attendance)

Department of Social Services Assisted

Full Days at Galaxy Play Only (Inclement Weather/Holiday's)

New or Returning?:*
1st new enrolled child = $25
1st re-enrolled child = FREE (WAIVED)
(Subsidy families pay enrollment fees if DSS does not)

What Grade is your child going into?*

2nd Child:*
2nd Child:

Gender First "Nickname" Last

Date of Birth:*

Which Program Site will your 2nd child attend?*

Auburn Elementary School

Christiansburg Primary School

Christiansburg Elementary @ Galaxy Play for all care -- MCPS bus will transport children to and from school

Falling Branch Elementary School

Kipps Elementary School

TAC at Galaxy Play (Not enrolled @ a site) - Full Days Only @ $50 per day/child

What will be your 2nd child's attendance status:*

Before Care (AM) Only

After Care (PM) Only

Before & After Care (AM & PM)

Wednesday Care Only (Full Day Rate)

Bundled Package: Before, After, & Wednesday's

Bundled Package: Before Care & Wednesday's

Bundled Package: After Care & Wednesday's

FLEX CARE ONLY: (DISCLOSURE: Spaces are based on availability -- Call office 540-382-3783 within 24 hrs of attendance)

FLEX AUTO: (DISCLOSURE: Spaces are based on availability -- Call office 540-382-3783 within 24 hrs of attendance)

Department of Social Services Assisted

Full Days at Galaxy Play Only (Inclement Weather/Holiday's)

New or Returning?:*
2nd new enrolled child = $25
2nd re-enrolled child = FREE (WAIVED)
(Subsidy families pay enrollment fees if DSS does not)

What Grade is your child going into?*

3rd Child:*
3rd Child:

Gender First "Nickname" Last

Date of Birth:*

Which Program Site will your 3rd child attend?*

Auburn Elementary School

Christiansburg Primary School

Christiansburg Elementary @ Galaxy Play for all care -- MCPS bus will transport children to and from school

Falling Branch Elementary School

Kipps Elementary School

TAC at Galaxy Play (Not enrolled @ a site) - Full Days Only @ $50 per day/child

What will be your 3rd child's attendance status:*

Before Care (AM) Only

After Care (PM) Only

Before & After Care (AM & PM)

Wednesday Care Only (Full Day Rate)

Bundled Package: Before, After, & Wednesday's

Bundled Package: Before Care & Wednesday's

Bundled Package: After Care & Wednesday's

FLEX CARE ONLY: (DISCLOSURE: Spaces are based on availability -- Call office 540-382-3783 within 24 hrs of attendance)

FLEX AUTO: (DISCLOSURE: Spaces are based on availability -- Call office 540-382-3783 within 24 hrs of attendance)

Department of Social Services Assisted

Full Days at Galaxy Play Only (Inclement Weather/Holiday's)

New or Returning?:*
3rd new enrolled child = $25
3rd re-enrolled child = FREE (WAIVED)
(Subsidy families pay enrollment fees if DSS does not)

What Grade is your child going into?*

4th Child:*
4th Child:

Gender First "Nickname" Last

Date of Birth:*

Which Program Site will your 4th child attend?*

Auburn Elementary School

Christiansburg Primary School

Christiansburg Elementary @ Galaxy Play for all care -- MCPS bus will transport children to and from school

Falling Branch Elementary School

Kipps Elementary School

TAC at Galaxy Play (Not enrolled @ a site) - Full Days Only @ $50 per day/child

What will be your 4th child's attendance status:*

Before Care (AM) Only

After Care (PM) Only

Before & After Care (AM & PM)

Wednesday Care Only (Full Day Rate)

Bundled Package: Before, After, & Wednesday's

Bundled Package: Before Care & Wednesday's

Bundled Package: After Care & Wednesday's

FLEX CARE ONLY: (DISCLOSURE: Spaces are based on availability -- Call office 540-382-3783 within 24 hrs of attendance)

FLEX AUTO: (DISCLOSURE: Spaces are based on availability -- Call office 540-382-3783 within 24 hrs of attendance)

Department of Social Services Assisted

Full Days at Galaxy Play Only (Inclement Weather/Holiday's)

New or Returning?:*
4th new enrolled child = $25
4th re-enrolled child = FREE (WAIVED)
(Subsidy families pay enrollment fees if DSS does not)

What Grade is your child going into?*

PREVIOUS CHILDCARE NAME - Type N/A if non-applicable.*

PHOTO CONSENT - Photos are reviewed prior to posting on Facebook to ensure proper exposure. TAC WILL NEVER publicly post children's names without parental consent!*

ELECTRONICS & TOYS AGREEMENT: TAC does not allow these items so that your child can fully experience the benefits our program has to offer. --- *REMOTE LEARNING Chromebooks are allowed during designated times*
I Agree to comply with TAC's "No Electronics or Toys" policy

Medical Information & Consents:

Pediatrician's Name:*

Pediatrician's Phone #:*

TEMPORARY MODIFIED SICK POLICY:
Children’s Health and Safety Policies Expanded A. New Sick Child Procedure – if your child has a temp of over 99.1 degrees please keep them home and they can return 72 hrs. fever free without medication. B. Daily health checks will be conducted every morning at drop off. Morning and Afternoon Drop off Procedures Modified A. Each child will have their temperature checked prior to entering facility B. All parents are required to wear face masks before entering the building C. Parents who may not be feeling well – we will deliver your child to you in the parking lot. Please call ahead and we will have your child ready. D. Children are required to wash hands when arriving at the facility.
Acknowledgement: I have read and will abide by the policies listed above.

CHILD ILLNESS & COMMUNICABLE DISEASE - If you're notified that your child is ill, you agree to pick your child up within 30 min's or no later than 1 hr. If your child or a member of your immediate household become ill or exposed to a Communicable Disease, you agree to notify TAC within 24 hrs.*
If my child is ill I agree to pick them up. I will notify the center in 24 hrs if exposed to a CD.

EMERGENCY MEDICAL RELEASE & HOSPITAL TRANSPORT - In the event I cannot be reached, I authorize TAC to act on my behalf for my child to receive emergency care, and if deemed necessary, arrange for emergency transport to the hospital of my choice.*

In the event your child sustains an injury while in our care but is NOT transported to the hospital or doctor from our site location, you agree to contact the main office (540-382-3783) within 24 hrs should you decide at a later time to take your child to the hospital or doctor to be evaluated. Per Virginia State Licensing Standards, The Adventure Club is mandated to report any medical treatment sought for the child's injury after the child has been picked up from our program.

Hospital Preference:*

Allergies, Special Needs, or Medication:*

If medication needs to be administered, please click the link below to the Medicine Consent Form and have the pediatrician complete it. With the completed form, provide your child’s medicine in its original box to the director of the center. Describe any specific details in the box below. Download Medication Consent Form

Specific Instructions for Emergency Medical Care & Hospital Transport:

Parent/Guardian Information:

Who does the child live with?:*

Relation to Child:*

1st Parent (Primary Payer):

First Last

Full Physical Address (PO Box is not a valid address): City State ZIP Code

Cell Phone #:*

Name of Cell Phone Provider*

Email Address - Please check your email regularly for important notices & account statements.*

Employment Status*

Va state licensing requires that we obtain your current employers address and phone # if you are currently employed.

Employed
Unemployed

Employer's Name:*

Employer's Physical Address (PO Box is not a valid address): City State ZIP Code

Employer's Phone #:*

Relation to Child:*

2nd Parent:

First Last

Is the 2nd parent's physical address the same as the 1st parent?*

Yes
No. Please complete address information below.

Full Physical Address (PO Box is not a valid address): City State ZIP Code

Cell Phone #:*

Name of Cell Phone Provider*

Email Address - Please check your email regularly for important notices & account statements.*

Employment Status*

Va state licensing requires that we obtain your current employers address and phone # if you are currently employed.

Employed
Unemployed

Employer's Name:*

Employer's Physical Address (PO Box is not a valid address): City State ZIP Code

Employer's Phone #:*

Authorized Emergency Contacts:

MUST Provide 2 Emergency Contacts that live within 1 hr of child's location. CANNOT BE PARENT/GUARDIANS!

Prefix:*

1st Contact:

First Last

Relation to Child:*

Cell Phone #:*

Full Physical Address (PO Box is not a valid address): City State ZIP Code

Prefix:*

2nd Contact:

First Last

Relation to Child:*

Cell Phone #:*

Full Physical Address (PO Box is not a valid address): City State ZIP Code

Parental Agreements:

BEHAVIORAL DISCLOSURE: The Adventure Club Team takes pride in providing a fun and safe environment for all of the children in our program. When parents, children, and The Adventure Club Team are all "on the same page" the children benefit immensely. Please refer to our Parent Handbook for further information.

I agree and understand the steps The Adventure Club will take if my child does not adhere to these expectations.

WITHDRAWAL AGREEMENT: 2 weeks notice of withdrawal MUST be submitted to TAC's main office via email at tac@the-adventureclub.com in writing or additional fees will apply.*
WITHDRAWAL AGREEMENT: 2 weeks notice of withdrawal MUST be submitted to TAC's main office via email at tac@the-adventureclub.com in writing or additional fees will apply.
I Agree to Submit a 2 Week Written Notice to tac@the-adventureclub.com.

PARENT HANDBOOK: The Adventure Club reserves the right to make changes to any policy, procedure, tuition rates, fees, or other processes and information in this parent handbook, rate sheets, or our enrollment forms without prior notice. We reserve this right to maintain licensing compliance, stability, and integrity of the programs, and for the safety and security of the children & families enrolled in our programs, and for the staff that our company employs. A copy of our handbook can be found under "Program Information, Rates, & Forms" on our website.*
PARENT HANDBOOK: The Adventure Club reserves the right to make changes to any policy, procedure, tuition rates, fees, or other processes and information in this parent handbook, rate sheets, or our enrollment forms without prior notice. We reserve this right to maintain licensing compliance, stability, and integrity of the programs, and for the safety and security of the children & families enrolled in our programs, and for the staff that our company employs. A copy of our handbook can be found under "Program Information, Rates, & Forms" on our website.
I agree to review TAC's Parent Handbook

Parent Electronic Signature for Enrollment:*
First Last

Date Enrollment Submitted:*
MM slash DD slash YYYY

Payment Policies

VERY IMPORTANT ~ PLEASE READ THROUGH CAREFULLY

* NO-PAUSE TUITION ~ Services provided on school sites are retained per contractual agreements with MCPS, therefore tuition fees are charged continuously during regular and non-school days from the 1st day of school to the last day of school.

* ADD-ON DAY FEES ~ Attendance on (Inclement Weather/Holiday) NON-SCHOOL DAYS of care as well as early release and late openings requires an add-on day fee and will be auto debited within 1 business. ALL full days of care will be hosted at our Adventure Club at Galaxy Play.

* FLEXIBLE CARE ONLY ~ All attendance will be deducted from your pre-paid hrs. Should your child attend more hrs than what you have available causing you to fall into a negative balance, you will be required to pay the balance due at a rate of $9 for each hour your negative. Balances are sent weekly via emailed statement. Purchased hrs are Non-Refundable. Unused hrs will carry over to the next year.

* FLEX AUTO ~ All attendance will be deducted from your pre-paid hrs. Once your flex time hits the 5 hour mark, you will receive an alert via text and email letting you know a re-charge will occur within 24 hours. At that time we will use the payment you submitted during enrollment to process 20 hours at the Flex AUTO rate (unless asked to charge more hours). To request a higher increment of hours 40/80, email us at tac@the-adventureclub.com. Balances are sent weekly via emailed statement. Purchased hrs are Non-Refundable. Unused hrs will carry over to the next year.

* UNPAID TUITION & LATE PAYMENTS ~ We require payment by auto debit ONLY. Weekly tuition is processed each Friday prior to week of attendance, or monthly according to our billing schedule on our rate sheet. If payment is returned for NSF, you will be charged a $35 processing fee. Payment in full will be expected no later than Wednesday to avoid suspension of care until the balance is paid.

* VENDOR DISCOUNT QUALIFICATIONS: MCPS & CCPS EMPLOYEES ~ Employment verification is required for all vendor employees before discounts are applied.

* LATE PICK-UP FEES ~ Any child clocked out of our system at 6:01pm or later WILL BE CHARGED A FEE, NO MATTER THE REASON FOR BEING LATE! (ie; vehicle breakdown, personal emergency, heavy traffic or car accidents, illness, working later than usual, etc.) Fees are as follows: $10 for the 1st 5 min's, and $1 a minute thereafter. Fees will be auto debited from your account.

Vendor Discounts

Do you currently work for any of the following vendors?*

I currently work within the MCPS system. (Discounts WILL NOT be applied until employment is verified)

I currently work within the CCPS system. (Discounts WILL NOT be applied until employment is verified)

I do NOT work for MCPS or CCPS

N/A - Only enrolling for full days at Galaxy Play

Payment Frequency Options

We accept Visa, MC, Check Card, or Checking Account Withdrawal (we do NOT accept Cash, Checks, AMEX or Discover).

Billing Cycle:*

Full Time AM Only, PM Only, AM & PM, Wednesday Only, OR Bundled Package Options including Wednesday’s:
select "Weekly".

Flex Care Only:
If enrolled for drop-in care only at your child's school site, choose "Flex Care Only" then choose how many hours to purchase. *KEEP IN MIND THE CHANGES TO FLEX CARE THIS SEMESTER*

Flex AUTO:
If enrolled for drop-in care only at your child's school site and want to have your hours auto re-charged for 10% off regular flex rates, choose "Flex AUTO" then choose how many hours to purchase. Re-charges will occur in 20 hour increments unless told to do otherwise via email: tac@the-adventureclub.com.

Full Days of Care Only at Galaxy Play (Inclement Weather/Holiday's):
If you only need care on Holiday's & Inclement Weather Day's, choose "TAC @ Galaxy Play Only $50/day per child".
Weekly
Flex Care
Flex Auto
TAC @ Galaxy Play Only $50/day per child (charged the next business day)

Pay Per Day Selection*
Group A Hours: 12:15 pm to 6:00 pm Group B Hours: 6:45 am to 12:45 pm M, T, TH, & F *Select the days you need*
Monday
Tuesday
Thursday
Friday

Choose how many flex hours to purchase:*
* Payment WILL BE PROCESSED upon receipt of enrollment!

* NEW families enrolling MUST choose an increment of hours to purchase to be actively enrolled.

* Returning families who have a positive balance of hours left over from last school year may choose not to purchase hours at this time (Please check with the account management team (tac@the-adventureclub.com or chat live) to be sure you have enough hours banked on your account before your child starts).

Payment Method Selection

How would you like to pay your tuition & fees?*
We accept: Visa, MC, Check Card, or Checking Account Withdrawal (ACH). (we do not accept Cash, Checks, AMEX or Discover)

Credit/Check Card

Checking Withdrawal (ACH)

Name as it appears on the card or checking account:*
First Last

*
Billing Address City State Zip Code

Phone #:*

Email Address:*

Credit/Check Card #:*

CONFIRM Credit/Check Card #:*

Expiration Date:*

Please enter the month & year in the following format: mm/yyyy

3 digit security code on back of card:*

Name of Financial Institution:*

Routing Number:*

Checking Account Number:*

CONFIRM Checking Account Number:*

Debit Authorization Agreement

Charges that may be automatically debited from your credit card or checking account will include the following as applicable:

* Registration fees. (these fees are Non-Refundable)
* Weekly and monthly tuition charges.
* Late payment fee of $35.
* Add-On day fees for full days of care $21.
* Add-On day fees for early release & late opening $10.
* Late pick-up fee per our policy (see parent handbook.
* Non-Sufficient Funds or Declined Payment fee of $35.
* Early Withdrawal Fee of $50 (min 2 wks written notice required).
* Approval for charges submitted via phone or email authorization.
* Negative balance of flex hrs owed at a rate of $9.00 hr.

Payment Agreement Confirmation

*
By typing my name below, I acknowledge that I have read the payment policies in this agreement. I understand that I am responsible for all tuition & fees that I incur upon receipt of this enrollment and while my child is actively enrolled in TAC and I authorize TAC to debit due charges from my account information provided on this form. I understand that failure to comply with said payment policies could result in applicable late fees, suspension, and/or termination from the program.

Electronic Signature for Payment Agreement:*
First Last

If after clicking submit you remain on the same screen, please scroll back through the form to complete highlighted areas and resubmit.

Adventure Club Enrollment Form 2021

Adventure Club School Enrollment 2021

TO AVOID DELAY IN ENROLLMENT, PLEASE COMPLETE THIS FORM IN IT'S ENTIRETY!

Child Information & Consents:

1st Child:

2nd Child:

3rd Child:

4th Child:

Medical Information & Consents:

Parent/Guardian Information:

1st Parent (Primary Payer):

2nd Parent:

Authorized Emergency Contacts:

1st Contact:

2nd Contact:

Parental Agreements:

Payment Policies

Vendor Discounts

Payment Frequency Options

Payment Method Selection

Debit Authorization Agreement

Payment Agreement Confirmation

If after clicking submit you remain on the same screen, please scroll back through the form to complete highlighted areas and resubmit.