TO AVOID DELAY IN ENROLLMENT, PLEASE COMPLETE THIS FORM IN IT'S ENTIRETY! How did you hear about us?* Facebook A Friend Google Roadside Advertizement Brochure 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) School Term Enrollment Selection ~ Please choose one of the following:* 2021-22 CURRENT Fall School Term 2022-23 Fall School Term If you are applying for both the CURRENT 2021-22 Fall School Term as well as the 2022-23 School Term, you will have to complete a separate enrollment form for each! 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 Carroll County 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:REQUIRED DOCUMENTS - NEW FAMILIES ONLY!UPLOAD: 1. Proof of birth (BIRTH CERTIFICATE), recent immunizations, and last physical/well visit. Your child CANNOT START UNTIL RECEIVED! 2. Parents are required to obtain these documents. ADVENTURE CLUB DOES NOT REQUEST DOCUMENTS FROM THE SCHOOLS! Click this link to complete needed forms if you have not done so already for the school: School Entrance Health Form (PDF) -- THESE MUST BE COMPLETED BY YOUR CHILD'S PHYSICIAN. 4. YOU MAY UPLOAD THEM BELOW OR FAX to 540-382-6529 or SCAN & EMAIL to: admin@the-adventureclub.com Drop files here or Select files Max. file size: 100 MB. How many children are you enrolling?*1 Child2 Children3 Children4 Children Program Start Date?* MM slash DD slash YYYY 1st Child:*1st Child: (M)(F) Gender First "Nickname" Last Date of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Which Program Site will your 1st child 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. Pre-Paid Flex AUTO: We now offer Flex Auto (Flex hours at 5% 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. * 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 rate. Auburn Elementary Christiansburg Elementary @ Galaxy Play for all care -- MCPS bus will transport children to and from school Christiansburg Primary @ Galaxy Play for all care -- MCPS bus will transport children to and from school Falling Branch Elementary Kipps Elementary Margaret Beeks TAC at Galaxy Play - Full Days Only (no before/after care) 1st Child: 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. ***IF FILLING OUT A FORM, YOU WILL NEED TO EITHER UPLOAD IT BELOW, SCAN & EMAIL IT TO tac@the-adventureclub.com OR Fax it to us at 540-382-6529*** Medication Consent (PDF) VA Athsma Action Plan (PDF) General Healthcare Plan (PDF) Food Allergy & Anaphylaxis Emergency Care Plan (PDF)No Allergies or Special NeedsYes - Please describe for which child in the text box belowNEW FAMILIES ONLY -- REQUIRED DOCUMENTS!UPLOAD MEDICAL DOCUMENTS HERE:Max. file size: 100 MB.Special Needs or Medication Details:What will be your 1st child's attendance status:* Morning (AM) care only Afternoon (PM) care only Morning & Afternoon (AM & PM) care Flex Care ONLY Flex AUTO (Save 5%) Full Days at Galaxy Play Only Department of Social Services Assisted Foster Care New or Returning?:*NewReturning1st 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?*Rising Kinder (Pre-K)Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade 2nd Child:*2nd Child: (M)(F) Gender First "Nickname" Last Date of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Which Program Site will your 2nd child 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. Pre-Paid Flex AUTO: We now offer Flex Auto (Flex hours at 5% 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. * 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 rate. Auburn Elementary Christiansburg Elementary @ Galaxy Play for all care -- MCPS bus will transport children to and from school Christiansburg Primary @ Galaxy Play for all care -- MCPS bus will transport children to and from school Falling Branch Elementary Kipps Elementary Margaret Beeks TAC at Galaxy Play - Full Days Only (no before/after care) 2nd Child: 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. ***IF FILLING OUT A FORM, YOU WILL NEED TO EITHER UPLOAD IT BELOW, SCAN & EMAIL IT TO tac@the-adventureclub.com OR Fax it to us at 540-382-6529** Medication Consent (PDF) VA Athsma Action Plan (PDF) General Healthcare Plan (PDF) Food Allergy & Anaphylaxis Emergency Care Plan (PDF)No Allergies or Special NeedsYes - Please describe for which child in the text box belowNEW FAMILIES ONLY -- REQUIRED DOCUMENTS!UPLOAD MEDICAL DOCUMENTS HERE:Max. file size: 100 MB.Special Needs or Medication Details:What will be your 2nd child's attendance status:* Morning (AM) care only Afternoon (PM) care only Morning & Afternoon (AM & PM) care Flex Care ONLY Flex AUTO (Save 5%) Full Days at Galaxy Play Only Department of Social Services Assisted Foster Care New or Returning?:*NewReturning2nd 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?*Rising Kinder (Pre-K)Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade 3rd Child:*3rd Child: (M)(F) Gender First "Nickname" Last Date of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Which Program Site will your 3rd child 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. Pre-Paid Flex AUTO: We now offer Flex Auto (Flex hours at 5% 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. * 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 rate. Auburn Elementary Christiansburg Elementary @ Galaxy Play for all care -- MCPS bus will transport children to and from school Christiansburg Primary @ Galaxy Play for all care -- MCPS bus will transport children to and from school Falling Branch Elementary Kipps Elementary Margaret Beeks TAC at Galaxy Play - Full Days Only (no before/after care) 3rd Child: 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. ***IF FILLING OUT A FORM, YOU WILL NEED TO EITHER UPLOAD IT BELOW, SCAN & EMAIL IT TO tac@the-adventureclub.com OR Fax it to us at 540-382-6529** Medication Consent (PDF) VA Athsma Action Plan (PDF) General Healthcare Plan (PDF) Food Allergy & Anaphylaxis Emergency Care Plan (PDF)No Allergies or Special NeedsYes - Please describe for which child in the text box belowNEW FAMILIES ONLY -- REQUIRED DOCUMENTS!UPLOAD MEDICAL DOCUMENTS HERE:Max. file size: 100 MB.Special Needs or Medication Details:What will be your 3rd child's attendance status:* Morning (AM) care only Afternoon (PM) care only Morning & Afternoon (AM & PM) care Flex Care ONLY Flex AUTO (Save 5%) Full Days at Galaxy Play Only Department of Social Services Assisted Foster Care New or Returning?:*NewReturning3rd 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?*Rising Kinder (Pre-K)Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade4th Child:*4th Child: (M)(F) Gender First "Nickname" Last Date of Birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Which Program Site will your 4th child 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. Pre-Paid Flex AUTO: We now offer Flex Auto (Flex hours at 5% 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. * 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 rate. Auburn Elementary Christiansburg Elementary @ Galaxy Play for all care -- MCPS bus will transport children to and from school Christiansburg Primary @ Galaxy Play for all care -- MCPS bus will transport children to and from school Falling Branch Elementary Kipps Elementary Margaret Beeks TAC at Galaxy Play - Full Days Only (no before/after care) 4th Child: 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. ***IF FILLING OUT A FORM, YOU WILL NEED TO EITHER UPLOAD IT BELOW, SCAN & EMAIL IT TO tac@the-adventureclub.com OR Fax it to us at 540-382-6529** Medication Consent (PDF) VA Athsma Action Plan (PDF) General Healthcare Plan (PDF) Food Allergy & Anaphylaxis Emergency Care Plan (PDF)No Allergies or Special NeedsYes - Please describe for which child in the text box belowNEW FAMILIES ONLY -- REQUIRED DOCUMENTS!UPLOAD MEDICAL DOCUMENTS HERE:Max. file size: 100 MB.Special Needs or Medication Details:What will be your 4th child's attendance status:* Morning (AM) care only Afternoon (PM) care only Morning & Afternoon (AM & PM) care Flex Care ONLY Flex AUTO (Save 5%) Full Days at Galaxy Play Only Department of Social Services Assisted Foster Care New or Returning?:*NewReturning4th 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?*Rising Kinder (Pre-K)Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th GradePREVIOUS CHILDCARE NAME - Type N/A if non-applicable.* FIELD TRIPS:*I Agree to allow my child to attend field tripsI Opt-Out of my child attending any field tripsPHOTO CONSENT - Photos are reviewed prior to posting on Facebook to ensure proper exposure. TAC WILL NEVER publicly post children's names without parental consent!*I Agree to Allow Photos of My ChildI Do Not Allow Photos of my ChildELECTRONICS & 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 #:*TEMPORARY MODIFIED SICK POLICY:*Children’s Health and Safety Policies Expanded A. Sick Child Procedure – if your child has a temp of over 100 degrees, please keep them home and they can return 48 hours after if fever free without medication. B. Daily health checks will be conducted every morning at drop off. Morning and Afternoon Drop off Procedures Modified C. Each child will have their temperature checked prior to entering facility D. Face mask mandate lifted on 2/22/2022 – not required but recommended. E. 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. F. 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. I authorize TAC staff to provide emergency care or hospital transport.Not authorized - Please follow specific instructions in text box belowHospital Preference:*Carilion RadfordLewis Gale BlacksburgLewis Gale SalemTwin County Regional Specific Instructions for Emergency Medical Care & Hospital Transport: Parent/Guardian Information:Who does the child live with?:*Both Parents - SAME HomeBoth Parents - SPLIT Home1st Parent Only - Legal CustodyLegal GuardianRelation to Child:*1st Parent (Primary Payer):Biological-ParentStep-ParentFoster-ParentOther - Legal Guardian* First Last * Full Physical Address (PO Box is not a valid address): City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Employer's Phone #:*Relation to Child:*2nd Parent:Biological-ParentStep-ParentFoster-ParentOther - Legal GuardianDeceased/Unavailable* 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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:*Mr.Ms.1st Emergency Contact:*1st Emergency Contact: First Last Relation to Child:*GrandmotherGrandfatherAuntUncleFamily FriendSisterBrotherSocial WorkerStep MotherStep FatherFoster MotherFoster FatherOtherCell Phone #:*Address:* Full Physical Address (PO Box is not a valid address): City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Prefix:*Mr.Ms.2nd Emergency Contact:*2nd Emergency Contact: First Last Relation to Child:*GrandmotherGrandfatherAuntUncleFamily FriendSisterBrotherSocial WorkerStep MotherStep FatherFoster MotherFoster FatherOtherCell Phone #:*Address:* Full Physical Address (PO Box is not a valid address): City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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.*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.*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.*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:* MM slash DD slash YYYY Payment PoliciesVERY 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 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, 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 DiscountsDo 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 do NOT work for this vendor. 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 ", 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". 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. 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 5% 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 PlayIf you only need care on NON-school days, choose "Full Days-Daily Rate Option.* 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 ", 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". 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. 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 5% 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 PlayIf you only need care on NON-school days, choose "Full Days-Daily Rate Option. Weekly -- (NON-SCHOOL DAYS WILL BE HELD @ GALAXY PLAY) Weekly w/Flex Hrs (to be used for AM Only or PM Only Flex Care alongside Weekly --- MUST BUY FLEX HOURS FOR THIS TYPE) Flexible Care Only Flex AUTO Full Days Only $60/day per child @ Galaxy Play -- (DO NOT CHOOSE THIS IF YOU WANT A WEEKLY BILLING!) DSS Assisted (Copay if any will be outlined by DSS) 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).20 hrs - $16040 hrs - $28880 hrs - $518.40We are a returning family and do not needs hrs at this time20 Flex AUTO hrs - $15240 Flex AUTO hrs - $273.6080 Flex AUTO hrs - $492.48Payment Method SelectionHow would you like to pay your tuition & fees?*We accept: Visa, MC, Credit 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Zip Code Phone #:*Email Address:* Credit/Check Card #:* CONFIRM Credit/Check Card #:* Expiration Date:* Please enter the month & year in the following format: mm/yyyy3 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 $30. * 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 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.<