Adventure Club Enrollment Form

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:*

Child Information & Consents:

How many children are you enrolling?*

Which Program Site will your child/ren attend?*

Child Care on NON-SCHOOL DAYS:
* If you only need care for your child K-12 yrs on NON-School days, you may enroll at Galaxy Play Only at a daily rate of $60 per child, each day.
* If you child is enrolled for Before & After care at one of our school sites, they will attend Galaxy Play on all NON-School days at a rate of $30 per child, each day.
* We provide breakfast, afternoon snack (parents need to pack a lunch), bouncy house fun, STEM activities, Lego's, board games, arts & crafts, arcade games, large indoor area for physical activity and team games, and outdoor rocket playground.

Pre-Paid Flexible Care:
For children who only need random drop-in care, you may purchase pre-paid Flex Hours in increments of: 20 hrs @ $160, 40 hrs @ $288, or 80 hrs @ $518.40.
* Flex hrs are Non-Refundable. Unused hrs will carry over to next school year.
* Once enrolled, there's no need to call ahead to drop your child off. Just bring them as needed during our regular before & after school hours.
* You may also utilize our Galaxy Play location for non-school days using your available hours.

Enrollment for the "BEFORE & AFTER" Program:
* Available for children needing care before and/or after school care paying a flat weekly or monthly rate.

Program Start Date?*

*

1st Child:

Gender First "Nickname" Last

Date of Birth:*

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

New or Returning?:*

1st new enrolled child = $50
1st re-enrolled child = $35
(Subsidy families pay enrollment fees if DSS does not)

What Grade is your child going into?*

*

2nd Child:

Gender First "Nickname" Last

Date of Birth:*

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

New or Returning?:*

2nd new enrolled child = $25
2nd re-enrolled child = $30
(Subsidy families pay enrollment fees if DSS does not)

What Grade is your child going into?*

*

3rd Child:

Gender First "Nickname" Last

Date of Birth:*

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

New or Returning?:*

3rd new enrolled child = $25
3rd re-enrolled child = $25
(Subsidy families pay enrollment fees if DSS does not)

What Grade is your child going into?*

*

4th Child:

Gender First "Nickname" Last

Date of Birth:*

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

New or Returning?:*

4th new enrolled child = $25
4th re-enrolled child = $25
(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.*

FIELD TRIPS:*

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.*

I Agree to comply with TAC's "No Electronics or Toys" policy

Medical Information & Consents:

Pediatrician's Name:*

Pediatrician's Phone #:*

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: 1 week notice of withdrawal MUST be submitted to TAC's main office or additional fees will apply.
I Agree to Submit a 1 Week Notice

*
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 Forms" on our website.
I agree to review TAC's Parent Handbook

Parent Electronic Signature for Enrollment:*
First Last

Date Enrollment Submitted:*

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 full days of care 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 $10 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.

* 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, LGMRH, and NRVCS 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 for LGMRH or NRVCS. (Discounts WILL NOT be applied until employment is verified)
I do NOT work for any of these vendors.
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).

*
Full Time AM or PM Care w/Alternate Flex Care:
If you chose to enroll AM or PM but would also like to use flex hrs alternately, choose "Weekly w/Flex Hrs or Monthly w/Flex Hrs", then choose how many hrs to purchase.

Full Time AM and/or PM Care (NO flex hrs needed):
If enrolled full time for AM, PM or both, choose "Weekly or Monthly".

Flex Care Only:
If enrolled for drop-in care only at your child's school site, choose "Flex Care Only" then choose how many hrs to purchase.

Full Days of Care Only at Galaxy Play
If you only need care on NON-school days, choose "Full Days-Daily Rate Option.
Weekly
Weekly w/Flex Hrs
Monthly
Monthly w/Flex Hrs
Flexible Care Only
Full Days Only - Daily Rate Option

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

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

* Returning families who have a positive balance of hrs left over from last school year may choose not to purchase hrs at this time (Please check with accounts manager to be sure you have enough hrs 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 #:*

Expire Date:*
MM
DD
YYYY

If your card only shows the MM/YYYY, you may just enter the last date of the month in the "DD" space.

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.
* Late pick-up fee per our policy (see parent handbook.
* Non-Sufficient Funds fee of $35.
* Early Withdrawal Fee of $50 (min 1 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.

Contact our Main Office at (540) 382-3783

Adventure Club Enrollment Form

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.