SAP application

Ready To Enroll?

Welcome! We are excited to get to know your child and family better. By filling out these forms, you will help us understand your child's interests and needs, so we can provide the best possible care and education. Thank you for choosing us as your partner for your child's growth.

Enrollment

Samara After-school Program (SAP)

"Helping Kids To Stick With It."

First and Last Name

Pronouns Preferred

DOB

Primary Address

Grade (2024-2025 School Year)

Please describe in your own words your child’s strengths/challenges

How do you hope SAP may help your child?

Parent/Guardian Information

Your First and Last Name

Phone

Employer

School History

Current School Placement

Teacher(s)

Therapies History

Directions: Please list any special services your child is currently receiving or has received in the past two years.

Speech/Language

School

Private

Start Date

If in the past, what was the reason for discontinuation?

Counseling

School

Private

Start Date

If in the past, what was the reason for discontinuation?

Tutoring

School

Private

Start Date

If in the past, what was the reason for discontinuation?

Other:

School

Private

Start Date

1) Please Describe. 2) What was the reason for discontinuation?

Consent Statement -Medical Release Permission Form

I hereby grant permission for my child whose name is: ________, and hereinafter shall be referred to as a “participant”, to participate in SAP at/through the Samara Learning Center.

I further acknowledge, understand and agree that by taking part in SAP there is a possibility of physical illness or injury (minimal or serious) and the participant is assuming the risk of such injury by participating.

I accept risks

I allow a hospital or doctor to treat my child without parent’s consent (unless it is a matter of lifeor death), while under the supervision of Samara Learning Center.

I agree

Insurance Name

Policy and Group Numbers

Allergies

Current Medication(s)

Emergency Contact

First and Last name

Phone

Please list additional adults authorized to collect your child from SAP.

Signature

Web, Social Media, & Marketing Release Form

Samara Learning Center, Samara's collaborators, news/information-based publication may post photographs and/or videos of my child and their work on electronic media, promotional/news/information material, including but not limited to web pages, social media, or newspaper/magazine articles. Nothing more than my child's age or grade level will be assumed to be allowed to be connected to any use. My child's name will not be associated with any of the images unless I am specially contacted and I express my permission for each occurrence.

Yes, I permit this

No, I do not permit this

Signature

Quarterly Enrollment

Directions: Select the days of the week you would like your child to attend. Samara predicts that space will fill quickly. We suggest you select dates for each quarter. Payment is due three weeks prior to each quarter in order to secure childcare. You will be invoiced accordingly. Our fees are $16.40/hr. Our cancelation policy is stated in the payment contract that follows.

Quarter 1: 09/09/24-11/08/24

Mondays (9 days)

Tuesdays (9 days)

Wednesdays (8 days)

Thursdays (8 days)

Fridays (8 days)

Early Bird payment due: 08/19/2024

Monday 2:15-5:30 pm

Tuesday 2:15-5:30 pm

Wednesday 1:00-5:30 pm. No childcare 10/30

Thursday 2:15-5:30 pm. No childcare 10/31

Fridays 2:15-5:30 pm. No childcare 11/01

Quarter 2: 11/12/24- 02/01/25

Mondays (7 days)

Tuesdays (9 days)

Wednesdays (9 days)

Thursdays (8 days)

Fridays (8 days)

Early Bird payment due: 10/21/2024

Monday 2:15-5:30 pm . No childcare 11/25, 12/23, 12/28, 12/30, 01/20

Tuesday 2:15-5:30 pm. No childcare 11/26, 12/24, 12/31

Wednesday 1:00-5:30 pm. No childcare 11/27, 12/25, 01/01

Thursdays 2:15-5:30 pm. No childcare 11/28, 12/26, 01/02, 01/30

Fridays 2:15-5:30 pm. No childcare 11/29, 12/27, 01/03, 01/31

Quarter 3: 02/03/25- 04/11/25

Mondays (8 days)

Tuesdays (9 days)

Wednesdays (9 days)

Thursdays (9 days)

Fridays (9 days)

Early Bird payment due: 01/13/2025

Mondays 2:30-5:00 pm. No childcare 02/17, 03/24

Tuesdays2:30-5:00 pm. No childcare 03/25

Wednesdays1:00-5:00 pm . No childcare 03/26

Thursdays 2:30-5:00 pm. No childcare 03/27

Fridays 2:30-5:00 pm. No childcare 03/28

Quarter 4: 04/14/25- 06/20/25

Mondays (7 days)

Tuesdays (8 days)

Wednesdays (7 days)

Thursdays (7 days)

Fridays (7 days)

Early Bird payment due: 03/17/2025

Monday 2:30-5:00 pm. No childcare 05/26

Tuesday 2:30-5:00 pm

Wednesday 1:00-5:00 pm. No childcare 04/16

Thursday 2:30-5:00 pm. No childcare 04/17

Fridays 2:30-5:00 pm. No childcare 04/18

Preferred e-mail for Invoice

Childcare Payment Contract

Directions: Please initial the following statements.. By initialing below, I verify that I have read this policy. I will abide by it or voluntarily choose to forfeit my childcare.

Payments are due in advance of service. Payments are due three weeks prior to the beginning of each quarter (or the initiation of service). If payment is past due by 28 days, an interest rate of 5% will be added. Fees compound monthly.

Forms of payment accepted:

Cash

Check

Money Order

Credit Card (with 3% QB fee)

Debit Card (with 1% QB fee)

Samara’s Refund Policy is as follows: If you cancel more than two weeks before the registered quarter have occurred, 100% will be refunded. A 50% refund will be given to cancellations made one week prior to the quarter.

Obligations of Samara After-school Program (SAP):

SAP will structure social/emotional and educational lessons in such a way as to optimize the benefit of the student.

SAP makes no promises or warranties with regards to a student's performance as a result of any tutoring provided. However, progress or concerns will be communicated to the Parent/Guardian.

SAP shall keep confidential all information of the student.