Calvary Learning Academy
Parent’s Day Out 2016 – 2017 School Year Registration Form *A non-refundable registration fee of $100 MUST accompany this form to reserve your place in the PDO program. ($75 for each additional child or program) Make checks payable to Calvary Learning Academy.
Parent’s Day Out Operates Tuesday – Friday, 9:00am to 3:00pm Schedule Choices
9:00am – 1:00pm or 11:00am – 3:00pm
One Day/Week Two Days/Week Three Days/Week Four Days/Week
$70/month $140/month $210/month $280/month
9:00am – 3:00pm $95/month $190/month $285/month $380/month
We service children at a minimun age of 12 months and walking steadily, through 5 years. We follow a balanced calendar, from the middle of August through the middle of May. Classes are scheduled to begin the week of August 8, 2016. Your child may attend one, two, three, or four days per week. The annual tuition is broken down into 10 equal monthly payments. You will receive a letter confirming your registration and your child’s classroom placement for the school year. Thank you! Please return this completed form and registration fee to: Calvary Learning Academy Tonya Conover, PDO Director 575 W. Northfield Drive
Brownsburg, IN 46112 For more information call 852-2594, or email Tonya Conover at
[email protected].
Parent’s Day Out Application for Enrollment My child will attend PDO on: (Circle)
Tuesday
Wednesday
Thursday
Friday
Time: _______________________________________________________ My tuition will be: $ __________________ per month. (You will be notified within two weeks if we do not have space for your child on your requested days.) Child’s full name: _________________________________________________________________________ Name to be used in class:____________________________________________________________________ Age: (As of 8/1/16) _____________ Date of birth: ______ / ______ / ______ Sex: M_______ F_______ Address:__________________________________________________________________________________ Street
City
State
Zip
Home phone:_______________ Mom’s cell: ___________________Dad’s cell:_______________________ Father’s name: ___________________________________ Occupation:_____________________________ Place of employment: _____________________________ Work phone: ____________________________ Mother’s name: ___________________________________Occupation:_____________________________ Place of employment: ______________________________ Work phone:_____________________________ Emergency contact person:_________________________________ Phone:___________________________ Parent’s marital status:_________________________ Child lives with: ____________________________ Email address_____________________________________________________________________________ Does your child have any special needs or allergies? _____________________________________________ Calvary Learning Academy has permission to use my child’s picture on their website, Facebook, or brochures. (No names will be used to identify the child.) Yes_____ No______ Church affiliation:________________________________________________________________________ (Please include the name of your family’s church home.)
PLEASE FILL OUT THE ATTACHED AUTOMATIC DEBIT FORM TO COMPLETE REGISTRATION ** For office use only: Class Assignment________________________________________ Lottery #____________________ R $_____________C________ M_________ OH_________D_________ W____________________
Tuition Payments Made Easy Calvary Learning Academy REQUIRES automatic tuition payments. The process is very simple and will not only have you writing one less check each month, it will also eliminate the possibility of a late tuition payment. To begin, simply fill out the Automatic Debit Authorization Form, attach a voided check, and turn in with your registration packet. We cannot accept a deposit slip from your savings account, so if you do not have a checking account, please get a letter from your bank authorizing this monthly withdrawal from savings. 5th,
Each month on the your tuition payment will automatically transfer from your preferred banking account into Calvary’s bank account. If you do not have sufficient funds in your account to cover the withdrawal, you will receive notice of non-sufficient funds and be required to pay the tuition in cash along with a $20 penalty. The first transfer will occur on August 5, 2016 and the last transfer will occur on May 5, 2017. You may make changes to this form any time by stopping in the office. Tuition payment is not subject to adjustments due to illness, vacation, absences or weather closings. Yearly tuition is divided into 10 equal payments. If you have any questions or concerns about Automatic Tuition Payments, please contact Shellody Brenton, bookkeeper, at Calvary’s office 317-852-2541.
CALVARY LEARNING ACADEMY AUTHORIZATION FOR DIRECT TUITION PAYMENT I authorize Calvary Learning Academy and First Merchants Bank to initiate debits from my (check one) _____Checking _____Savings account. This authority will remain in effect August 5, 2016 through May 5, 2017. I can stop payment of any entry by notifying my financial institution and Calvary Learning Academy 3 days before my account is charged. I understand that debits will only be processed on the 5th of each month. A voided check must be attached to this form. Printed Name:_______________________________ Signature:__________________________________ Today’s Date:_______________________________ My Bank’s Name is:___________________________ My Bank’s Routing Transit # is:__________________ (The routing number is the first 9 numbers at bottom left of your check) My Account Number is:________________________ Date to Start Debiting My Account:_______________
Each account debit will be the following amounts: Tuition (Child’s Name)_______________________ $ __________ Tuition (Child’s Name)_______________________ $ __________ Tuition (Child’s Name)_______________________ $ __________
Total Debit Each Month
$ __________
(Please attach a voided check or letter from your bank)
