After School Programs 2017-2018

Child's Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Birth Date*

MonthDayYear

Parent's Name*

First NameLast Name

E-mail*

Parent Name

First NameLast Name

Phone Number*

Area CodePhone Number

Alternate Phone Number*

Area CodePhone Number

Emergency Contact 1*

First NameLast Name

Emergency Contact 1 Phone Number*

Area CodePhone Number

Emergency Contact 2*

First NameLast Name

Emergency Contact 2 Phone Number*

Area CodePhone Number

Please describe any behavioral or health concerns, including allergies

Families who would like to enroll for shorter or longer terms can contact Monique at Monique@creativerootspdx.com to make arrangements.

Creative Roots generally does not offer the option to drop in, but in some circumstances arrangements can be made by contacting Monique at Monique@creativerootspdx.com.

Full Program Rate, yearly rate

Full Time After School Program (2:15-6pm) - $580/monthPart-Time After School Program (2:15-5pm) -$435/monthPart-Time After School Program (2:15-4pm) -$385/monthOther

Please list the dates you would like your child to attend

Creative Roots Refund Policy

Payment for classes which are cancelled by Creative Roots at any time will be refunded in full.

Although we are unable to offer refunds, if your child is unable to attend the after school program due to illness or unforeseen circumstances, he or she may be eligible to receive a credit towards future Creative Roots programs.

All questions and concerns should be brought to the attention of Monique at Monique@creativerootspdx.com.

Thank you!

Please include your child's teacher and room number, if you would like us to pick him/her up from Chapman Elementary at 2:15pm

I would like to receive your e-newsletter. Please add me to your mailing list.*

YesNo

I give permission for my child's photo and photos of his/her artwork to be used by Creative Roots for promotional purposes. Creative Roots does not post photos of children on social media and we do not ID any children*

YesNo

Additional comments or information

I have read and agree to the information above, including the Creative Roots refund policy.*

After School Program Registration