ACTON-BOXBOROUGH COMMUNITY EDUCATION EXTENDED DAY GRADES 1-6 PROGRAM, 2016-2017 ADMINISTRATION BLDG., 15 CHARTER RD., ACTON, MA 01720

(978) 266-2525

Child’s Name (last, first)_________________________________

DOB_________ Gender: M / F

Home Address_________________________________________

Home Phone____________________

School ______________Program: Admin__Conant__Gates__

Grade ________

Father/Guardian Name ___________________________

Mother/Guardian Name _______________________

Business Phone ________________________________

Business Phone _____________________________

Cell Phone_____________________________________

Cell Phone _________________________________

Email Address __________________________________

Email Address ______________________________

MONTHLY TUITION - SCHEDULE Please: Check the box to indicate the number of days per week and the time, and then circle the days of the week.

Days Per Week AM ONLY

Full Week – Five days

PM ONLY

AM & PM

$225

$508

$594

Please circle the Days 4 days

M

T

W

Th

F

$193

$426

$505

3 days

M

T

W

Th

F

$152

$323

$384

2 days

M

T

W

Th

F

$106

$216

$266

1 day

M

T

W

Th

F

$54

$113

$140

An additional fee of $25/month will be charged for children attending on Thursday afternoons. Not applicable for children enrolled five days a week.

REGISTRATION FEE $40.00. (Maximum registration fee per family $75.00) Note: Fees are non refundable. Registration paid $_________________

If my child is accepted, I understand and agree to the following:   

Tuition is paid in 10 equal payments with the first non-refundable June 2017 payment due by August 1 and monthly thereafter. st If you register after August 1 , the first payment will be the non-refundable tuition for June 2017 plus the current month. Transportation to the program in the morning and pick-up at the close of Extended Day is the responsibility of the parent. th It is presumed that the child is enrolled for the full academic year. We require written notice by the 10 of the month for a schedule change to occur the following month. There is a one month notice required for withdrawal. See Policies and Procedures document for details.

Parent Signature:________________________________

Date: ____________________________