ACTON-BOXBOROUGH COMMUNITY EDUCATION EXTENDED DAY GRADES 1-6 PROGRAM, 2017-2018 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

$235

$525

$615

Please circle the Days 4 days

M

T

W

Th

F

$200

$440

$520

3 days

M

T

W

Th

F

$160

$335

$395

2 days

M

T

W

Th

F

$110

$225

$275

1 day

M

T

W

F

$56

$120

$145

An additional fee of $50/month will be charged for children attending on Thursday afternoons due to the Early Release Days. Not applicable for children enrolled five days a week. THURSDAYS ONLY: $160/month

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 2018 payment due by May 28, 2017. If you register after August 15th, the first payment will be the non-refundable tuition for June 2018 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. It is presumed that the child is enrolled for the full academic year. We require written notice by the 10 th 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. I consent to personally identifiable information about my child being shared between staff of the Acton-Boxborough Regional School District and the Acton-Boxborough Community Education Extended Day program, orally and in writing, in order to assist staff members with fulfilling their professional responsibilities as it relates to my child. This authorization will remain in effect until 6/30/2018.

Parent Signature:________________________________

Date: ____________________________