2016-2017 ELEMENTARY ENROLLMENT FORM
How did you hear about us? ___________________________________________
Child’s Name
_____Gender ___________ Date of Birth_____/_____/_____
Address
City
State/Zip
_____
Select School: Indian Springs Roan Forest Cibolo Green Bulverde Creek Encino Park Other: _____________
Grade: ________Classroom:___________________ Summit Start Date____/____/____Withdrawal Date____/____/____
Father’s Name
Employer
Business Phone
Cell Phone
Email
Home Church
Mother’s Name
Employer
Business Phone
Cell Phone
Email
Home Church
Does child live with both parents?
Yes No
If no, list whom child lives with and marital status of that parent.
Is there a custody order on file?
Other children in the family:
Name
School
Age
Name
School
Age
Name
School
Age
Emergency Contact and Pick Up (other than parents; ID will be required)
Name
Relationship
Address
Contact Phone
Name
Address
Relationship
Contact Phone
Name
Address
Relationship
Contact Phone
I have received and agree to the policies of Summit Christian Learning Center. I give permission for Summit
Christian Learning Center to pick up my child afterschool from the above referenced Elementary School.
Signature
Date: _______________________________________
I understand it is my responsibility to change any information in this enrollment form as needed. By this signature I
am verifying that this information is true and correct to the best of my knowledge. In consideration for my child
being allowed to participate in activities at Summit Christian Center, I hereby release, discharge, indemnify and
agree to hold harmless Summit Christian Center, it’s directors, officers and employees, agent and all volunteer
personnel from any and all liability for personal injuries and or damages, injury or illness that my be suffered by
(Child Name)___________________________________. We further agree to indemnify and hold harmless Summit
Christian Center, it’s directors, officers, employees, agent and all volunteer personnel for any claim and or
damages, or its agents are required to pay as result of any injury or damage including reasonable attorney fees,
litigation expenses and courts costs.
Signature
_____
_____________________Date
MEDICAL INFORMATION AND RELEASE FORM
Child’s Name
Date of Birth_____/_____/_____
Child’s Physician
_____________________________________________________
Physician Address: ________________________________________Phone
_____________
______ My Child has NO special/medical needs, injuries, or allergies (Environmental, food and medical)
______ My Child has special/medical needs, injuries, or allergies (Environmental, food and medical)
Please List Below:
Please answer all of the following questions, if yes please describe:
Does your child have any hearing or speech difficulty?
Is your child taking any medication?
Does your child have asthma or wheezing?
Does your child have epilepsy?
Does your child have febrile (fever) seizures?
Is your child allergic to insect bites or stings?
Has your child ever had chicken pox?
Has your child had allergic skin reactions?
Has your child been hospitalized or had a
Medical condition in the last 12 months?
Any other surgical or medical information?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
Yes
Yes
No
No
____________________________________
____________________________________
My child’s immunizations / health records are current. I have provided Summit Christian Center with a copy of
current records and Physician Statement Request form (see attached) My child will not be accepted into care until
current shot records are received, Physician Statement must be received within one week of start date.
Signature_____________________________________________________________________________________
In the event that I cannot be reached to make arrangements for emergency medical treatment at the time of
illness or accident, I hereby authorize Summit Christian Center to take my child to the closest emergency room.
Signature
Date
PARENT NOTIFICATION OF CUSTODY ISSUES
We cannot legally prevent a child from being picked up by a parent or person designated by a parent. If parents
are legally separated or divorced, we cannot restrict the days or times parents pick up their children. Parent must
be responsible to adhere to their custody agreement and or decide between themselves which days and times
each of them will pick up their child. Summit Christian Learning Center is legally obligated to release the child to
their parent. If a parent as no legal right to pick up their child, or has a restraining order in effect, the school MUST
HAVE A COPY OF THE COURT ORDER stating such on file. Otherwise, either parent may check the child out of the
school with proper identification.
I have read the above statement regarding pick up custody issues of legally separated or divorced parents. This
form should be signed regardless of your marital status. You signature states that you understand Summit Christian
Learning Center Policy regarding custody issues.
Child(ren) Names:________________________________________________________________
Parent / Guardian Signature: _____________________________________________________
Date: ______________________________________
Medical Waiver
My Child _____________________________________ has his/her immunization records. TB tine skin
test record, hearing and vision screenings on file at his/her elementary school.
School Name: ___________________________________________
Address: ________________________________________________
_______________________________________________________
Phone: _________________________________________________
Parent signature: _________________________________
Date Signed: _________________
Elementary Program and Pricing Sheet 2016-2017
ALL FEES AND TUITION ARE NON-REFUNDABLE
2016 Summer Camp Program (Entering 1st-5th grade)
____$100 Summer Fee
____$185 Weekly tuition
_____Monday – Friday 7AM-7PM, June 6-August 19, 2016
2016-2017 Afterschool Program (Kindergarten-5th grade)
____$100 Fee
____$80 Weekly Tuition
____$90 Weekly Tuition for Early Release Schedule
_____Monday-Friday afterschool-7:00pm, August 21, 2016-June 1, 2017
_____Closed June 2, 2017
_____Summer Camp 2017 begins June 5, 2017
Parent Signature: _________________________________________ Date: ______________

Late pick up fees are assessed at the rate of $1.00 per minute beginning at 7:05 pm (Parents’ Initials) _________

During vacation breaks and holiday times, an activity fee may be charged. Activity fees are for additional activities outside
our normal planned curriculum. Parent will be notified 1 week in advance of activity fee options. (Parents’ Initials) _________

In the event I choose to end my relationship with Summit Christian Learning Center and withdraw my child, a two week
written notice will be given. (Parents’ Initials) _________
OFFICE USE ONLY:








Summer Fee of $100 per child.
School Year Fee $100 per child.
Early Bird School Year Fee $50 per child. February 8 –March 21, 2016 only.
10% Sibling Discount on oldest child’s tuition.
10% Family Discount off 3 or more children in care
10% Military, First Responder and Educator Discount on total tuition.
(Parent or Guardian only, current ID required)
10% Summit Church Member Discount
(Parent or Guardian only, Must complete New Member Class)
Summit Staff Member Discount
Name: _______________________________________ Date: __________________
PHOTO RELEASE FORM
Dear Parents,
During the school year, opportunities arise to provide positive information and publicity about our
programs and events to the general public or specific audiences. In some cases, we may receive
requests from the news media or professional persons to interview, photograph, and/or film students for
news or non-profit publications, television or radio broadcasts, or for educational information and
training or various publications and brochures printed by the Summit Christian Center.
Permission is needed for your child to be the subject of any news media publicity or included in our
publications. Please sign this form and return it to the Learning Center, where it will be kept on file for
future reference.
I give Summit Christian Center permission to use my Child Picture and First Name in:
___ Newsletters/ Classroom
___ Website
___ Summit Social Media
___ Local Television Ads
___ None of the above
*No last names or other personal information will ever be used*
________________________
Child’s Name
__________________________
Parent’s Signature
_____________
Date
SUNSCREEN/INSECT REPELLENT FORM
If you are desiring for your child to wear Sunscreen or Insect Repellent, we do encourage parents to
apply it at home. If you are unable to do so, we are willing to apply the Sunscreen/Insect repellent for
you, upon parent request. Having signed the acknowledgement below, you will simply need to bring in
the Sunscreen/Insect Repellent labeled with your child’s full name, in order for it to be applied that day.
Please be sure to notify your child’s teacher that you are requesting for the Sunscreen/Insect repellent to
be applied. The Sunscreen/Insect Repellent must be physically handed to the caregiver and not simply
left in the child’s cubby or bag.
Your signature below authorizes Summit Christian Learning Center to apply Sunscreen or Insect
Repellent to your child upon request, as well as acknowledges your awareness of this policy.
Child’s Name ____________________________________________
________________________________________________
Parent or Guardian Signature
_________________
Date
Summer Camp 2016 Program Schedule and
Field Trip Agreements
Summit Christian Learning Center has Full Time Summer Programming Monday-Friday from 7am-7pm.
_____ (Initials) Camp Dates are from June 6, 2016-August 19, 2016.
_____ (Initials) Parent BLAST OFF! Orientation and Information night is May 31, 2016 at 6:00pm.
_____ (Initials) Field Trips are optional and all permission and payments must be made by due dates.
_____ (Initials) June 6-10, Sun, Moon and Stars Adventure
_____ (Initials) June 13-17, Miles to Mercury
_____ (Initials) June 20-24, Voyage to Venus
_____ (Initials) June 27-July 1, Mission to Mars
_____ (Initials) Closed July 4, 2016
_____ (Initials) July 5-8, Earthen Adventure
_____ (Initials) July 11-15, Giant Jupiter
_____ (Initials) July 18-22, Shuttle to Saturn
_____ (Initials) July 25-29, Vacation Bible School week at Summit. 8:30-12:00 M-F
_____ (Initials) July 25-29, Uranus Undercover after VBS 12:30-7:00pm M-F
_____ (Initials) August 1-5, Nights of Neptune
_____ (Initials) August 8-12, Space Odysseys
_____ (Initials) August 15-19, Galaxy Grooves
I, ______________________________, give permission for my child, ______________________________, to attend
the following field trips:
JUNE (all June field trip payments must be made by June 6, 2016)
_____ Animal World and Snake Farm, $10 (Tuesday, June 7, 2016)
_____ San Antonio Zoo, $10 (Thursday, June 9, 2016)
_____ Young Chef’s Academy, $10 (Tuesday, June 14, 2016)
_____ Planetarium, $5 (Thursday, June 16, 2016)
_____ Art Works, $5 (Thursday, June 23, 2016)
_____ Astro Bowl, $$ (Tuesday June 28, 2016)
_____ G Rated Movies, $2 (Thursday, June 30, 2016)
JULY (All July field trip payments must be made by July 1, 2016)
____ Witte Museum, $10 (Tuesday July 5, 2016)
____ Picnic in a Park, $5 (Thursday, July 7, 2016)
____ Tower of Americas, $12 (Tuesday, July 12, 2016)
____ Doseum, $ TBD (Thursday, July 14, 2016)
____ Monster Golf, $10 (Tuesday, July 19, 2016)
____ The Rollercade, $10 (Thursday, July 21, 2016)
____ Snowball and Snowcones, $5 (Thursday, July 28, 2016)
AUGUST (All August field trip payments must be made by August 1, 2016)
___ San Antonio Aquarium, $10 (Tuesday, August 2, 2016)
___ Water Slides at Summit, $5 (Thursday, August 4, 2016)
____ Laser Legend, $20 (Tuesday, August 9, 2016)
____ The Meadows Center Glass Bottom Boat $TBD (Thursday, August 11, 2016)
____ Natural Bridge Caverns, $10 (Tuesday, August 16, 2016)
____ Flying L Dude Ranch $TBD (Thursday, August 18, 2016)
Each Monday, the specifics of the week’s field’s trips (i.e., addresses, names of attending chaperones,
etc.) will be posted on the classroom doors along with being emailed to the parents. . I understand that
my child must be present and checked into care by 8:30am on Field Trip Days. I understand that Field
Trip Itineraries may change and that I will be notified 48 hours in advance of changes.
Parent Name: ___________________________Parent Signature: ___________________________ Date: _________
DATES OF CLO
DATES OF CLOSURE
2016-2017 School Year
Full Time Program Hours of Operation
Summit Christian Learning Center has Full Time Programming for afterschool care during the traditional
NEISD school year.
We will be closed on the following days in observance of Federal Holidays, Christian Holidays, Local
Holidays, Holiday Breaks and Teacher In-Service Days.
_____ (Initials) September 5, 2016 (Labor Day)
_____ (Initials) September 23, 2016 (Teacher In-Service Day)
_____ (Initials) October 10, 2016 (Columbus Day)
_____ (Initials) November 24-25, 2016 (Thanksgiving Holiday)
_____ (Initials) December 23-26, 2016 (Christmas Holiday Observed)
_____ (Initials) January 2, 2017 (New Year’s Day Holiday Observed)
_____ (Initials) January 16, 2017 (Teacher in-service day)
_____ (Initials) February 20, 2017 (President’s Day)
_____ (Initials) March 13-17, 2017 NEISD Spring Break (Programming Available $185 per week)
_____ (Initials) April 14, 2017 (Good Friday)
_____ (Initials) April 28, 2017 (Battle of the Flowers)
_____ (Initials) May 29, 2017 (Memorial Day)
_____ (Initials) July 4, 2017 (Independence Day)
Parent Name: ___________________ Parent Signature: ___________________________ Date: __________
ALL ABOUT ME!
Attach recent photo of child here
Childs Name: ____________________________________________________________________
Age: ________ Eye color: ______________Hair color: _________________
Has your child attended school before? ____________ If so where? _________________________
What type of programming? _____________________________________________________________
What concerns do you have about your child in his/her adjustment to school? In what ways
would you like to see our program help your child?
Special Aptitude, Hobbies or Interests:
___________________________________________________________________________________________
Favorite song: _____________________________________________________________________________
Favorite food: _____________________________________________________________________________
Favorite book: _____________________________________________________________________________
Favorite toy: _______________________________________________________________________________
Favorite place to visit: ______________________________________________________________________
Best time of day: __________________________________________________________________________
People that live in my house: _______________________________________________________________
Special people in my life: __________________________________________________________________
Family pets: _______________________________________________________________________________
Please describe a typical day in the life of your child, daily routines, eating and sleeping
schedules, activities, outings, etc.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
__________________________________________________________________________________________
Learning to communicate and cooperate with other children and adults is an important part of
your child’s Learning Center experience. Any information you can provide about your child’s
abilities and style of communication and cooperating will be helpful to us in meeting the
needs of your child.
How does your child respond to new people? Is he/she shy around strangers or does
he/she appear happy and curious?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
How does your child behave in play situations with others? Does he/she enjoy observing
children play? Does he/she prefer to play next to another child or to share activities with
other children?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
How does your child show you that he/she has truly become comfortable with a stranger,
whether an adult or child?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
What techniques do you use to help your child feel comfortable with your visitors at home?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
What kinds of activities does your child enjoy with his or her favorite people?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________