Application Form - Viaquenti Academy

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Parent/Guardian 1.

Name:

Cell Phone:

E-Mail:

Home Address:

Home Phone:

City:

State

Zip:

Employer:

Hours of Employment:

Work Address:

Work Phone Number:

City:

State:

Zip:

Parent/Guardian 2.

Name:

Cell Phone:

E-Mail:

Home Address:

Home Phone:

State:

Zip:

Employer:

Hours of Employment

Work Address:

Work Phone Number:

City:

State:

Zip:

Medical Information

Pediatrician’s Name:

Phone:

Address:

Dentist’s Name:

Phone:

Address:

Health Insurance

Yes No

Company/HMO:

Group Number:

Identification Number:

Additional Child Information

My child has the following medical Problems:

My child is taking the following medicine(s):

My child has the following allergies:

My child has the following special needs:

Please put extra contacts in for emergency purposes

Name:

Phone Number:

Relation:

Another eemergency contact

Name:

Phone Number:

Relation:

Only the following people are hereby authorized to pick up my/our child from Viaquenti Academy in my/our absence (must be at least 18 years old). I/We understand that if anyone who is not listed needs to pick up my/our child me/us MUST call and email AHEAD with information to confirm the release. Picture ID will be needed to confirm that person’s identity in any case. If I/We want to withdraw the authorization of any person(s) authorized by me, I/We must do so in writing. Until it does so all authorized person(s) will be understood as authorized to pick up my/our child from Viaquenti Academy.

Additional Contact Information

Name:

Relation:

Home Address:

Phone Number:

City:

State:

Zip:

CHILD PICKING UP/VISITING AUTHORIZATION (N.J.A.C. 10:122-6.5(A)1)

Name:

Relation:

Home Address:

Phone:

City:

State:

Zip:

PERSON (S) PROHIBITED FROM PICKING UP/VISIT THE CHILD:

Name (1):

Relationship (1):

Name (2):

Relationship (2):

If a noncustodial parent is not included among those people authorized to pick up/visit the child and/or a person(s) is prohibited from pick up/visit the child, please explain below and attach a copy of appropriate court order.

If Applicable, please attach the court order here.

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SUBMISSION INSTRUCTIONS / TERMS AND CONDITIONS

1. I/We state that I/we are the parent(s)/guardian(s) having legal custody of the above child (referred as the “Student” or "Child") and attest that the information on this application is accurate. I/we hereby enroll the Student in Viaquenti Academy (referred to as the “School”) for this Academic Year.

2. I/We am/are to complete and submit a Student Application Form with a non-refundable fee of $50 to put my/our child on the list for enrollment.

3. I/We will be notified to sign up for a Playgroup Evaluation. My/Our child will participate in at least 1 Playgroup Evaluation to determine his/her eligibility. My/our child is not officially admitted until after a Playgroup Evaluation (Early Preschool and Infants are exempt).

4. Students applying for Early Preschool are required to enroll in one of our summer camp programs or in our After School program for at least one month. This policy is meant to help transition first time students into Viaquenti.

5. Class placements are determined by the child’s age on the first day of the Academic Year in September.

6. The prices are based on a full academic year of: a) 10 months (September to June) for Early Preschool to Pre- K. b) 12 months (September to August) for Infant classroom. Please note that the school requires a commitment for the full academic year.

7. If my/our child is accepted I/We must submit a Tuition Deposit equal in amount to 1 months of tuition to secure my/our child’s spot in the classroom. This tuition deposit is non-refundable and non- transferable. If I/We am not re-enrolling the Tuition Deposit will ONLY be applied as a credit to the last two months of my/our child’s tuition after the 1st full academic year: a) In a 10 months Academic Year my/our deposit will be applied to May & June, b) In a 12 months Academic Year my/our deposit will be applied to July & August. Note: Absolutely no credits will be made towards the tuition of summer camp or any other program.

8. If my/our child is accepted I/We am/are aware that before beginning to the first day at School, I/we shall submit all paperwork listed in the student's checklist. My/our child enrollment at the School shall be conditioned upon the full finished of all requirements.

9. At the time of enrollment, I/We must submit a yearly non-refundable student's material fee of: a) Infants & Waddlers; $300 for Half Day program, $390 for Full Day and Extended Day programs. b) Early preschool to Pre-K; $335 for Half Day program, $425 for Full Day and Extended Day programs. c) After School program; $190 for all classrooms. Note: Extended Day students do not have to pay the After School tuition or material fee; this is included in the Extended Day tuition and material fee.

10. Enrichment classes are included in the tuition or discounts.

11. I/We agree to pay in advance each month’s tuition. Tuition is due in advance by the 25th of each month (i.e. May tuition is due April 25th); this is the day that tuition payment will be withdrawn. Note: When the 25th falls on a non business day and/or a Holiday, the tuition payment will be withdrawn the previous Friday (i.e. the tuition due on April 25th (Saturday) will be withdrawn on Friday 24 th).

12. Tuitions will only be received electronically, so I/We authorize the School to automatically withdraw the payments due in the invoices. I/We will choose between the Recurring Payment Plans (RPP): a) RPP: ACH; tuition payment will be withdrawn from your account. b) RPP: Personal credit card; with this option I/we will be charged a fee per month.

13. I/We am/are aware that I/We will be charged a fee for: a) Late payment, a fee of 5% of the monthly tuition will be charged when payment is received after the 25th of the month. b) For late pickups or early drop off, a fee of a $1 per minute will be charged when my/our child is picked or dropped off outside of their scheduled time. c) Returned payment from automatic withdrawal, a fee of $12 charged by our Bank. The school will send a new invoice adding the fee and the next day will rerun the automatic withdrawal.

14. I/We understand that there will be no reductions in payments for child’s absences from the School. Tuition payments are for each month including the days in which the School may be closed for holidays, staff training, due to unforeseen circumstances and/or inclement weather.

15. Early drop off at 7:30a.m. is available at no additional charge.

16. Delayed pick up at 6:30 p.m. This service is offered on a month-to-month basis and is available for an additional charge of $75 per month. I/We understand that the school needs at least two students enrolled for this service.

17. I/We agree to comply with all school policies/requirements and understand that the school reserves the right to change them at any time without my/our approval. I/We acknowledge that all the Submission Instructions/Terms & Conditions in previous Student Application/Re-Enrollment & Tuition Agreement Forms are valid unless a specific clause is modified by this form.

18. Discounts: More than 1 discount may not be combined, if your family is eligible for more than 1 discount you will need to indicate which discount you would like to be applied. The following discounts only can be applied for the Academic Year 2021-2022. Please choose one if apply: a) 10% discount will be applied to the tuition if more than one sibling is enrolled in the school. b) 5% discount will be applied to the tuition if a full year payment is made, enrollment must begin in September. c) Other:

Please choose one if apply:

A) 10% discount will be applied to the tuition if more than one sibling is enrolled in the school. B) 5% discount will be applied to the tuition if a full year payment is made, enrollment must begin in September. C) Other:

By signing this form, I/we certify that I/we have read the above terms and conditions and fully understand and agree to abide by all the conditions and terms of this Agreement.

ENROLLMENT APPLICATION FORM N.J.A.C. 10:122-6.8

Parent/Guardian 1.

Medical Information

EMERGENCY CONTACT LIST

STUDENT INFORMATION

First Day of Enrollment:

Student's Name:

Gender

Birthday:

Present Age:

Age in Sep/Nov XXXX

Address:

Phone:

City:

State:

Zip:

Please select class/service in which you are enrolling your child.

Please Select (1) Class/Service

Half Day 7:30am - 12:00noon

Full Day 7:30am - 3:30pm

Extended Day 7:30am - 6:00pm

Please click only* what is applicable to the session that was selected.

INFANTS ( 3 months to 1 year old )

WADDLERS ( 1 year old- Transitional class )

EARLY PRESCHOOL ( 1.5 - 2 years old )

PRESCHOOL ( 2 to 3 years old )

PRE-K ( 3 to 5 years old )

All Classrooms - After School 3:30pm-6:00pm

All Classrooms - Extended pick up 6:00pm- 6:30pm

Program questions type here...

Parent/Guardian 1.

Name:

Cell Phone:

E-Mail:

Home Address:

Home Phone:

City:

State

Zip:

Employer:

Hours of Employment:

Work Address:

Work Phone Number:

City:

State:

Zip:

Parent/Guardian 2.

Name:

Cell Phone:

E-Mail:

Home Address:

Home Phone:

State:

Zip:

Employer:

Hours of Employment

Work Address:

Work Phone Number:

City:

State:

Zip:

Medical Information

Pediatrician’s Name:

Phone:

Address:

Dentist’s Name:

Phone:

Address:

Health Insurance

Company/HMO:

Group Number:

Identification Number:

Additional Child Information

My child has the following medical Problems:

My child is taking the following medicine(s):

My child has the following allergies:

My child has the following special needs:

Please put extra contacts in for emergency purposes

Name:

Phone Number: