Online Registration "*" indicates required fields Step 1 of 6 16% AASEP - Ainsworth After School Enrichment Program 2425 SW Vista Ave. Portland, OR 97201 (503) 223-9744 Child's Name* Birth Date* MM slash DD slash YYYY Date entered program MM slash DD slash YYYY Grade in 2021/22* Teacher (if known): AASEP begins at 2:15pm & concludes at 6:00pm Please select your desired schedule and then the days you wish your kid to assist.Select Schedule* Full time: [M thru F] 4 days/week: 3 days/week: 2 days/week: 2 days* Monday Tuesday Wednesday Thursday Friday 3 days* Monday Tuesday Wednesday Thursday Friday 4 days* Monday Tuesday Wednesday Thursday Friday Parents / GuardiansParent/Guardian 1* Home phone: Work phone: Cell phone:* Email Parent/guardian1 Address:* Zip: Employer: Occupation: Parent/Guardian 2 Home phone: Work phone: Cell phone: Email Address: Zip: Employer: Occupation: Our Registration Fee is $125.00 per family per year. This will be automatically billed upon confirmation of your registration. NO CHECKS OR CASH ⧫ Does your child have any life-threatening allergies or special concerns?* Does your child require an epi pen or inhaler? YES / NO (If “Yes”, please provide one to AASEP)* Yes No Is there a custody concern involving your child?* Does your child have an IEP or 504 plan?* What language(s) do you speak at home? Please give us any information that will help us to best care for your child (i.e., likes, dislikes, fears, favorite activities):Please list any health or physical limitations your child may have: Names & ages of other children in household: Are there other adults in your household? Please list names and relationships to your child. (This helps aid in decision-making in case of an emergency, bad weather etc., if you cannot be reached.)Name 1 Relationship Name 2 Relationship Name 3 Relationship Who is authorized to pick up your child (on a regular basis)? Please include phone numbers.Name 1 Phone # Name 2 Phone # Name 3 Phone # If neither parent can be reached, please contact: (at least two names and numbers of people who are local and may be available to pick up your child in case of an emergency, illness, or inclement weather.)Name 1* Phone #* Name 2* Phone #* Name 3 Phone # It is required, by State Certification, that we have your child’s doctor & dentist’s names and phone # on record. Please take this time to locate and record these numbers.Doctor* Doctor´s Address* Doctor's Phone* Dentist* Dentist´s Address* Dentist's Phone* Is your child receiving medication? Yes No I understand that participation in Ainsworth After School Enrichment Program (AASEP) requires that I agree to follow the policies stipulated in the Parent Handbook. Please sign here, and initial each item below:Signature*Date* MM slash DD slash YYYY SOME OF OUR MOST IMPORTANT RULES & ITEMS, FOR WHICH WE REQUIRE YOUR INITIALS. PLEASE READ CAREFULLYI will pay tuition and any fees/fines I owe by the tenth (10th) of each month, or I will pay an additional $10 late fee. I understand that if I am more than 4 weeks behind in payments, my child may be suspended from AASEP I will call to cancel scheduled childcare when my child is absent, or I will pay a $15 fine. This policy helps insure the safety of children using the Center. I will arrive by 6:00 pm to pick up my child, or I will pay $5/minute for every minute I am late On special Long Days (holidays, teacher planning days, etc.), I will sign up two days in advance, a full 48 hours, before the Long Day. If needed, I will cancel 48 hours before a Long Day, or I will be charged the cost of attending that special day. On Long Days I will send a lunch with my child. If the center provides a lunch, I will pay $15 I will not spank my child at AASEP. I understand that in Oregon it is not permitted in a licensed childcare facility. I will inform AASEP and sign a release form if my child will be participating in after school activities outside of the AASEP program, including clubs and class parties. If I fail to inform AASEP, I understand that my child may not be released for their activity. If my child needs medicine while attending AASEP I will sign a medical form in advance giving AASEP permission to administer it. The medicine will be in its original container with the child’s name, doctor’s name, current date, and dosage information. To withdraw my child from AASEP, I will provide two weeks written notice. I understand that AASEP does not offer refunds or pro-rate for partial months due to withdrawal My child may be taken on field trips by bus, under proper supervision, and with advance notice. I understand that all field trips will be billed to my account. My child has my permission to participate in water activities, such as a safe water toy competition. My child may have his/her picture taken and used for publicity and/or news purposes. I recognize that my child must be potty-trained to attend AASEP. AASEP has permission to use an anti-bacterial in cleansing my child’s cuts and scrapes and to administer sunscreen if needed. AASEP has permission to take or transport my child via ambulance to any available medical facility and to authorize emergency medical treatment at my expense AASEP has permission to take or transport my child via ambulance to any available medical facility and to authorize emergency medical treatment at my expense I recognize that Ainsworth After School Enrichment Program is a licensed facility, in compliance with the laws of the State of Oregon and that I can view their license on-site I understand that AASEP’s policies and procedures are subject to change due to the state, count, and PPS guidelines around COVID-19. I have read and understand the policies in the AASEP Parent Handbook Emergency AuthorizationState Law requires that we have written authorization from a child’s legal guardian to seek medical help in the event of a medical emergency. Signing the statement at the bottom of this letter will provide us with that authorization. Our policy in the event of a medical emergency is to contact you first. If we cannot contact you or if the medical emergency requires immediate response, we will act on behalf of the best interest of the child. I give permission for Ainsworth After School Enrichment Program - or its representative (over age 18) - to authorize emergency medical transport and treatment, if needed for my childPlease take my child to the following hospital:* Signature*Date* MM slash DD slash YYYY This authorization is good for this school year: August 1, 2021 – June 30, 2022 The Portland School District requires your signature for the following:I understand that Ainsworth School (Portland School District) provides the space for the AASEP program. Ainsworth School does not supervise the care, and I do not expect the school to take any responsibility for the care of my child or the way the facility is operated, even if the school staff has knowledge of any aspects of the day care provided. Furthermore, by signing below, I authorize my child’s school to share information about my student with the Program. This release also grants permission to AASEP to share information about my student with the school on a need-to-know basisSignature*Date* MM slash DD slash YYYY RECURRING PAYMENT PLAN AUTHORIZATION FORM: ACHAinsworth After School Enrichment Program 2425 SW Vista Ave. Portland, OR 97223 (503)-223-9744I authorize AASEP to initiate either an electronic debit or create and process a demand draft against my Checking or Savings Account for the purpose of collecting childcare related payments. I authorize AASEP to withdraw sufficient funds to pay my regular childcare fees that are due and payable. I authorize AASEP to use the third-party sender, Tuition Express, to process all payments. I acknowledge that the origination of ACH transactions to my account must comply with the provisioning of United States law.Account Holder’s Name:* Account Holder’s Phone Number:* Account Holder’s Email Address:* Account type* Checking Savings Routing Number:* Account Number:* Name of Bank:* This authorization will remain in full force and effect until I notify AASEP in writing of its termination. Notification must be received 5 business days in advance of termination date to permit Tuition Express and my bank reasonable time to act upon it.SignatureDate MM slash DD slash YYYY
"*" indicates required fields
Step 1 of 6
