TUITION RATES SCHOOL YEAR

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1 TUITION RATES SCHOOL YEAR REGISTRATION FEE: $65.00 per child DISCOUNTS: Family discount apply to families with two or more children in the Extended Day program. Full price is paid for the youngest child. The second and third child rate is at a discount. A 10% discount will be given to employees of the Milford School District. EXTENDED DAY PRESCHOOL WEEKLY CHILD CARE 1 ST CHILD 2 ND CHILD 3 RD CHILD Prechool w/extended Day 5 days per week $190. $171. $ Days of Preschool / 5 days of Extended Day $163. $149. $ Days of Preschool / 4 Days of Extended Day $153. $139. $123. EXTENDED DAY KINDERGARTEN WEEKLY CHILD CARE 1 ST CHILD 2 ND CHILD 3 RD CHILD Attend 5 days $137. $126. $110. Attend 4 days $124. $112. $110. Attend 3 days $100. $ 89. $ 80. *SPECIFIC DAY MUST BE INDICATED IF 4 DAYS OR LESS. *5 HOURS OR LESS (BLOCK OF TIME) EACH DAY IS $104. PER WEEK. *4 HOURS OR LESS (BLOCK OF TIME) EACH DAY IS $81. PER WEEK. STUDENT MAY ATTEND 5, 4, OR 3 DAYS PER WEEK. FAMILY DISCOUNT DOES NOT APPLY. SPECIFIC DAYS CANNOT BE CHANGED IF 4 DAYS OR LESS. FULL DAY KDG. 6 TH GRADE AM OR PM (AM KDG. MAY USE AM SESSION, PM KDG. MAY USE PM SESSION **SPECIFIC DAY MUST BE INDICATED IF 4 DAYS OR LESS. 1 st CHILD 2 ND CHILD 3 RD CHILD Attend 5 days per week $63. $56. $51. Attend 4 days per week $57. $52. $47. Attend 3 days per week $52. $47. $43.. FULL DAY KDG.- 6 TH GRADE AM AND PM. PRICE IS PER WEEK. SPECIFIC DAYS MUST BE INDICATED IF 4 DAYS OR LESS. 1 ST CHILD 2 ND CHILD 3 RD CHILD Attend 5 days per week $75. $67. $60. Attend 4 days per week $67. $57 $54. Attend 3 days per week $59. $53. $48. ALL DAY CARE FEES: Regular tuition is NOT charged for Spring or Winter Break. ALL DAY CARE FEES APPLY. YOU MUST SIGN UP FOR ALL DAY CARE IN ADVANCE. THE DAYS YOU ATTEND ARE THE DAYS YOU WILL BE CHARGED. 1 ST CHILD = $35. 2 ND CHILD = $33 3 RD CHILD = $31. **LIMITED AGREEMENT IS FOR STUDENTS NOT ATTENDING EXTENDED DAY REGULARLY. THEY ARE SIGNING UP TO ATTEND ALL DAY CARE OR SNOW DAYS. ALL DAY CARE FEES LISTED ABOVE APPLY. SCHEDULED ALL DAY CARE MUST BE PAID BY WEDNESDAY IN ADVANCE OF THE ACTUAL DATE OF ATTENDANCE. SNOW DAYS MUST BE PAID WHEN CHILDREN ARE DROPPED OFF. *EARLY RELEASE CHARGE FOR STUDENTS ATTENDING EXTENDED DAY IS $ LIMITED AGREEMENT STUDENTS FEE IS $23.40.

2 SCHOOL YEAR Milford Extended Day STUDENT REGISTRATION FORM School Year Office Use Only Reg Fee PD Date Received Teacher County SN Student ID # School: Grade School Year Male Female Student s Legal Last Legal First Legal Middle Preferred Date of Birth (mm/dd/yyyy) Home Phone Native Language Home Address: Street-Apt# City State Zip Code Legal Guardianship Are you the biological/adoptive parent(s) of the child? Yes No If no, what is your relationship to the child? Status of BIOLOGICAL/ADOPTIVE Parents: Married Divorced Widowed Separated Single/Never married If divorced, who has legal custody? Mother Father Shared Parenting If foster/guardian, please list Case Manager/Court Liaison: LEGAL PAPERS UNAUTHORIZED PICK UP Please complete information on father and mother, including contact numbers, regardless of marital status. Circle: Father/Guardian/Foster Parent Circle: Mother/Guardian/Foster Parent RESIDES here CONTACT ABOUT PAYMENT RESIDES here CONTACT ABOUT PAYMENT : Address: City/State/Zip: Home Phone: Cell/Pager: of Employer: Business Phone: Preferred address Step-Mother (if applicable): Work Phone: Cell/Pager: : Address: City/State/Zip: Home Phone: Cell/Pager: of Employer: Business Phone: 2 nd address Step-Father (if applicable): Work Phone: Cell/Pager: ***Monthly statements will be ed. Please provide address above.*** Child s Photo may be taken and displayed. Yes No Child Roster Yes No Parent Handbook Received Yes No Will Use Internet Special Needs IEP 1:1 Aide

3 Siblings Age Grade Lives with Authorized Pick Up List (other than parents)

4 EXTENDED DAY PROGRAM AGREEMENT (Grades KDG-6) The Parent/Guardian of (student name) and the Milford Exempted Village School hereby agrees to the following participation provisions of the Milford Extended Day Program: Parent/guardian will pay weekly Child Care fee of $ for their child to attend the indicated days per week. Make payments by Visa, MasterCard, Discover, check, or money order payable to MILFORD BOARD OF EDUCATION. (NO CASH) Child Care payments are due by Wednesday prior to the week of service, this includes All Day Care fees, Early Release fees. Payments are accepted at all sites, Milford Extended Day Office, or through mail. Failure to stay current on your account will result in dismissal from the program. At the time of registration a nonrefundable sixty-five dollars ($65) registration fee must be paid for Grades KD- 6. Late Pick Up Fee: The program closes at 6:30 p.m. After 6:30, you will be charged $20 per child for every 15 minutes or portions thereof, until your child is picked up. Continual late occurrences could jeopardize your position in the program. All medical conditions or special concerns that may affect the child s welfare while participating in the Milford Extended Day Programs should be disclosed by parents at the time of registration. I understand and agree with the provisions of this agreement. I will abide by these and other regulations of the Milford Extended Day programs as presented in the Parent Handbook while my child is a participant in the program. The Parent Handbook can be found online at *****Monthly statements ed. Please my statement to: *** Check Box if Parent/Guardian is a Milford Employee Parties responsible for payment must sign. First Parent Signature Date Second Parent Signature Date A.M. Session Sign in time 3 days per week (circle) M T W TH F 4 days per week (circle) M T W TH F 5 days per week (circle) M T W TH F P.M. Session Sign out time 3 days per week (circle) M T W TH F 4 days per week (circle) M T W TH F 5 days per week (circle) M T W TH F

5 MILFORD EXEMPTED VILLAGE SCHOOL DISTRICT EMERGENCY MEDICAL AUTHORIZATION FORM ( ) PURPOSE: To enable parents and guardians to authorize the provisions of emergency treatment or transportation for children who become ill or injured while under school authority, or during an emergency situation, when parents cannot be reached. NOTIFY THE SCHOOL IMMEDIATELY IF ANY INFORMATION CHANGES.(Ohio Revised Code ) (Please print or type AND SIGN FORM IN THE APPROPRIATE AREA on the reverse side). File:JO-E(5) EBBA-E TO THE PARENTS/GUARDIAN OF: STUDENT NAME STUDENT ID STREET ADDRESS DATE OF BIRTH GENDER: o Female o Male CITY, STATE,ZIP TELEPHON# GRADE RESIDENTIAL/CUSTODIAL PARENT or LEGAL GUARDIAN: Student LIVES with: (please check) and enter information below: o Father & Mother o Mother ONLY o Father ONLY o Shared Parenting o Foster Parent o Other NAME RELATIONSHIP FULL ADDRESS (if different than student s) HOME PHONE CELL PHONE WORK PHONE ADDRESS Additional space for address, if needed (indicate name): List three (3) names of persons to be contacted in the EVENT OF AN EMERGENCY: I understand that my child may be released to anyone on the list if ill, injured, or if an emergency occurs, and he/she must leave school. NAME RELATIONSHIP HOME PHONE CELL PHONE WORK PHONE MEDICAL PROBLEMS/ALLERGIES/SPECIAL NEEDS (Please check applicable box): Diabetes Bee or Insect Sting Hearing Impaired Emotional Problem Other (bite) Asthma Food Allergy Learning Visually Impaired Disability Seizures Medication Allergy Orthopedic History of Concussion Please provide detailed information regarding any above checked items: Medication your child takes daily: *** PLEASE REFER TO BACK PAGE FOR ADDITIONAL INFORMATION AND REQUIRED SIGNATURES ***

6 MILFORD EXEMPTED VILLAGE SCHOOL DISTRICT File: JO-E(5) EBBA-E For educational purposes, special medical problems, physical impairments or other facts concerning your child s medical history may be shared with teachers or other support staff involved in the academic setting. If you DO NOT CONSENT for the sharing of this information, you are required to state this in writing and submit your statement with this form to your school administrator. PART I OR II MUST BE COMPLETED - (only complete Part I OR Part II) PART I: TO GIVE CONSENT ~ A. I hereby GIVE CONSENT for the following medical care providers and local hospital to be called: Doctor: Phone: Dentist: Phone: Hospital: Phone: In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for (1) the administration of any treatment deemed necessary by above-named doctor, or in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery. B. I authorize Milford Exempted Village School District to release any information which I have provided this school district concerning any medical history, including information regarding allergies, medications, physical condition, etc. of the student named above to any employee of the school district and/or volunteer providing medical service to the school district who has responsibility for such student while the student is at school, participating in a school sponsored function, or is being transported by the school. SIGNATURE OF PARENT/GUARDIAN DATE *** Complete Part II ONLY if you have NOT COMPLETED PART I *** PART II: REFUSAL to Give Consent ~ I DO NOT GIVE my consent for emergency medical treatment for my child. In the event of illness or injury requiring emergency treatment, I wish the school authorities to take the following action: SIGNATURE OF PARENT/GUARDIAN DATE

7 Date School Rec d Date Trans Rec d School Year ALTERNATE TRANSPORTATION/SITTER REQUEST FORM Grades: KDG or Preschool Milford Exempted Village School District 5934 Buckwheat Rd, Milford, Ohio Telephone (513) Fax (513) Transportation cannot be provided if your child s sitter lives outside your school attendance area. Please allow five (5) working days to process your request. We are unable to honor telephone requests for alternate pick up and drop off locations due to liability. Please notify transportation and school if any information on this form changes. Thank you. Circle one Student School Grade AM or PM Student Address Parent/Guardian Teacher s Telephone Number of Parent (Home) Work Cell of Day Care/Sitter Milford Extended Day Phone Cell Sitter s Address 1039 St. Rt. 28 Milford, OH Parent/Guardian Signature Date AM KDG/PRESCHOOL STUDENT Date Request Begins Am Pick Up location M T W TH F Bus Time Noon Drop off location M T W TH F Bus Time AM session home bus PM KDG/PRESCHOOL STUDENT NOON session home bus Date Request Begins Noon Pick Up location M T W TH F Bus Time PM Drop off location M T W TH F Bus Time NOON session home bus PM session home bus Copy to driver Copy to transportation Computer Assigned Date and initial Date and initial Date and initial

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