Extended Day Membership Application 2023-2024
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What is your name as the Parent/Guardian of the scholar?
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What your address?
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What is your Home Phone Number? (if applicable)
What is your cell phone number? *
Please provide the names of each scholar, along with their grade level and homeroom teacher, for whom you are seeking enrollment in the extended day program.

Example:
Jane Smith 9th Grade Ms. Green
John Smith 3rd Grade Mr. Jones
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Cost of Extended School-Day program:
Daily Attendance Expectation: The Paideia Extended School-Day program is a daily enrichment program for your scholar. The activities build on each other throughout the week. Therefore, daily attendance is expected. I understand that frequent absences or early pickups may result in the scholar being dropped from the program. As the parent/guardian, please type your name below to acknowledge your understanding of this agreement.
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Pick-up Scholar(s) by 6:00 pm: I understand the Extended School-Day program ends at 6:00 pm. I agree to pick-up my scholar(s) from the Extended School-Day program no later than 6:00 pm or risk having my scholar(s) removed from the program and/or being charged the following late fees.

Fees: $15 within the first 15 minutes and $1/minute after the first 15 minutes. 

As the parent/guardian, please type your name below to acknowledge your understanding of this agreement.
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Scholar Behavioral Expectations: I understand that the Extended School-Day program has the same behavioral expectations and code of conduct consequences as the school-day program.

I agree to hold my scholar(s) accountable for behavioral infractions during the Extended School-Day program.

I understand that my scholar(s) may be withdrawn from the Extended School-Day program and possibly be suspended from the school day program for violations of the Paideia Code of Conduct.   

As the parent/guardian, please type your name below to acknowledge your understanding of this agreement.
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Hold Harmless Release: I hereby waive, release, absolve and agree to hold harmless Paideia Academies Inc, its directors, officers, organizers, sponsors, supervisory staff, participants, and any other affiliates for, from and against all liability because of any bodily injury, or property damage, known or unknown, which may occur as a result of the participation of the above mentioned child in any and all activities whether the result of negligence or for any other cause of the Paideia Academy.

I individually, and as a parent/guardian for my child, have read this release and understand all the terms.

I execute it voluntarily and with full knowledge of its significance.  

As the parent/guardian, please type your name and the date below to acknowledge your understanding of this agreement.
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Authorization to Produce and Use Audiovisual Materials:

YES: I do grant permission to Paideia Academy for the use of the photograph(s) and/or electronic media images in any presentation of any and all kind whatsoever. I understand that I may revoke this authorization at any time by notifying Paideia Academy in writing. The revocation will not affect any actions taken before the receipt of this written notification.

NO: I do not grant permission to Paideia Academy for the use of the photograph(s) and/or electronic media images in any presentation of any and any kind whatsoever. 

As the parent/guardian, please type your name, followed by either "yes" (to grant permission) or "no" (to decline permission), and include the date below to confirm your understanding of this agreement.
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Please list two emergency contacts other than those listed above:

Please list their name, their relationship to you and/or the scholar, their phone number, and their email

Example:
Jane Smith Sister 123-456-7890 janesmith@gmail.com
John Smith Uncle 321-654-9870 johnsmith@gmail.com
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Please list any medical problems or concerns
If emergency care is necessary and I cannot be contacted, I authorize Paideia Academy to act on my behalf. I hereby grant Paideia permission to have my scholar(s) receive emergency medical attention. 

As the parent/guardian, please type your name and the date below to acknowledge your understanding of this agreement.
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